Human papillomavirus infection and lung adenocarcinoma: special benefit is observed in patients treated with immune checkpoint inhibitors

BACKGROUND

Human papilloma virus (HPV) has been associated with the development and modulation of response in a series of neoplasms. In the case of lung adenocarcinoma, its role in etiology and pathogenesis is still controversial. Considering that this infection brings foreign epitopes, it could be of prognostic significance in patients with lung adenocarcinoma treated with immunotherapy.

METHODS

In a retrospective cohort study we evaluated the presence of HPV genomic material in lung adenocarcinoma primary lesions with the INNO-LiPA platform. Viral replication was also evaluated by detecting the presence of oncoprotein E6/E7 messenger RNA (mRNA) by quantitative RT-PCR. To confirm possible hypotheses regarding viral oncogenesis, vascular endothelial growth factor (VEGF) and hypoxia-inducible factor 1 (HIF1) were evaluated with stromal fibrosis and immunoscore.

RESULTS

A total of 133 patients were included in the analysis, of whom 34 tested positive for HPV, reaching an estimated prevalence of 25.6% [95% confidence interval (CI) 18.2% to 32.9%]. E6/7 mRNA was identified in 28 out of the 34 previously positive cases (82.3%). In immune checkpoint inhibitor (ICI)-treated patients, the median overall survival reached 22.3 months [95% CI 19.4 months- not reached (NR)] for HPV-negative and was not reached in HPV-positive (HPV+) ones (95% CI 27.7-NR; P = 0.008). With regard to progression-free survival, HPV- patients reached a median of 9.2 months (95% CI 7.9-11.2 months) compared to 14.3 months (95% CI 13.8-16.4 months) when HPV was positive (P = 0.001). The overall response rate for HPV+ patients yielded 82.4% compared to 47.1% in negative ones. No differences regarding programmed death-ligand 1, VEGF, HIF1, stromal fibrosis, or immunoscore were identified.

CONCLUSIONS

In patients with HPV+ lung adenocarcinoma, a significant benefit in overall response and survival outcomes is observed.

Electronic nicotine delivery systems (ECs) and COVID-19: the perfect storm for young consumers

The COVID-19 pandemic caused a change in our society and put health systems in crisis worldwide. Different risk factors and comorbidities have been found that increase the risk of mortality when acquiring this infection. The use of alternative devices to the cigarette like the electronic cigarettes, the vapers have been studied widely and generators of great controversy since it has been discovered that they also produce different pulmonary affections. When developing the SARS-CoV2 infection, different theories have been generated about the greater predisposition to a worse prognosis of people who use electronic cigarettes; however, the information on this continues in discovery. A group of experts made up of oncologists, infectologists, pulmonologists, and epidemiologists met to review the literature and then generate theories about the impact of electronic cigarettes on SARS-CoV2 infection.

[Morbidity and mortality in a series of patients suffering from intraperitoneal neoplasia treated with peritoneal cytoreduction and hyperthermic intraperitoneal chemotherapy at the Fundación Santa Fe de Bogotá Teaching Hospital (ONCOLGroup--ATIA study)]

BACKGROUND

The procedure of radical peritonectomy followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is considered the standard treatment for peritoneal cancers.

AIMS

To evaluate various outcomes in a cohort of patients with peritoneal tumors treated with HIPEC.

METHODS

Twenty-four patients consecutively treated with radical peritonectomy plus HIPEC within the time frame of November 2007 to July 2010 were enrolled; 15 (62%) had tumors of appendicular origin, 4 (16.7%) had primary peritoneal tumors, 2 had ovarian carcinomas and there was one case of colon cancer, one carcinosarcoma and one hemangioendothelioma. Mean age was 53 years (range: 26-68) and median follow-up was 14.2 months (range: 1-32). Demographic data, histology, peritoneal cancer index (PCI), surgical procedure characteristics, recurrence-free survival (RFS), and overall survival (OS) were all evaluated. Short-term morbidity and mortality were also determined.

RESULTS

Complete cytoreduction was achieved in 18 patients (75%). Mean PCI was 15 (<10: 41% and >10: 58%), and the median (range) for surgery duration, length of stay in the Intensive Care Unit, parenteral nutritional support, and hospital stay were 12,5 (7-20) hours, 11,4 (2-74) days, 13,8 (12-65) days, and 29,1 (10-90) days, respectively. One patient (4%) died 6 months after the procedure, due to multiple associated complications. Considerable morbidity was seen in 52% of cases, including thromboembolic events (41%), catheter-related bacteremia (29%), fistulas (29%), and nephrotoxicity (25%). Six patients (25%) recurred after a median of 21 months of RFS.

CONCLUSIONS

Cytoreductive surgery plus HIPEC in well-selected patients presenting with tumors that affect the peritoneum is a procedure that can be carried out in Colombia with an adequate safety and effectiveness profile. Mortality was similar to that reported in the international literature.

Cost-effectiveness analysis of first-line treatment for metastatic renal cell carcinoma (mRCC) in Colombia (ONCOLGroup study)

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Background: Renal cell carcinoma has increased its incidence by 126% since 1950. A local study developed a complete economic evaluation of sunitinib versus IFN in first-line treatment of mRCC in Colombia, finding that sunitinib was more cost-useful and cost-effective. Methods: A Markov model was developed using 6-week cycles for evaluating the cost-effectiveness of four interventions (IFN, sunitinib, bevacizumab+IFN, sorafenib) approved as first-line treatment for mRCC in Colombia. The model used the third-party payer perspective and a 5-year time-line; it also presumed that all the patients (pts) continued with active treatment until progression when it became acceptable to continue with a second-line treatment or BSC. Overall survival (OS) and progression-free survival (PFS) curves of IFN were used as reference framework; they were obtained form a published clinical trial. The hazard ratios (HR) for PFS and OS were estimated for comparing new generation medicaments with IFN. The information about frequency of use and health service cost units consumed in Colombia was taken from a series of 24 pts treated in Manizales, Pereira, Medellín and Bogotá. Service costs were requested from an external consultant and corresponded to the average value billed by the EPSs, calculated from 33 sources of information which were representative of the country's market. The cost of the medicaments was obtained from LCLC. The costs and benefits were discounted annually at 3%. (all cost are presented in Colombian pesos Col$ 2008 with an exchange rate 1 USD = 1836.20 Col$). Results: Incremental analysis indicated a difference of 41.1 million Col$ in the average total cost of treatment when Sunitinib was compared to IFN; in contrast, comparing sorafenib and Bevacizumab+INF to sunitinib demonstrated that the average total cost was less for the sunitinib by 8.3 and 104.2 million Col$, respectively. Additionally, the ratios of incremental cost-effectiveness by life years (LY) gained demonstrated sunitinib's simple dominance over sorafenib and the combination of bevacizumab+IFN, and an average by LY gained of 100.5 million Col$ compared to IFN. Conclusions: Sunitinib is the most cost-effective option as first-line treatment for mRCC pts in Colombia.

[Table: see text]

Triticum vulgare mouthwashes (TVM) for patients (pts) with oral mucositis (OM) induced by chemotherapy and chemoradiotherapy (ONCOLGroup study)

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Background: OM is a frequent complication of cancer therapy in Colombia. Triticum vulgare has been reported to effectively treat mucosal and skin disturbances. Methods: To evaluate the safety and efficacy of TVM for the control of OM induced by chemoradiotherapy in pts with head and neck cancer (HNC) and by chemotherapy in pts with haematological malignancies (HM). Thirty-one pts received TVM delivered in a spray four times daily to the whole oral cavity until the OM being resolved. The primary endpoint was the OM grade evaluated daily using the Nebraska scale (NS). Secondary endpoints were OM duration, weight loss, pain and TVM tolerance; the latter two were evaluated using a visual analogue scale (VAS). Results were compared with data from 42 pts with OM treated with saline mouthwashes (SM) in a previous clinical trial. Results: Nineteen pts had HM and 12 had HNC; those with HM developed OM on day 9 of chemotherapy (range, 7–14), whilst those having HNC did so towards day 17 of chemoradiation (range, 13–26). Using NS 38% of pts developed GI OM, 46% GII OM and 16% GIII OM. Moderate and severe OM occurred more frequently amongst HNC pts (8 vs 1, p = 0.047), mean OM duration in HNC pts was 12±4.5 days, whilst it was 7 ±3 days (p = 0.047) in pts with HM. Median OM duration in pts treated with TVM was 5.4 days (range, 2–9) vs 7 days (range 1–17) for pts treated with SM (p = 0.048). TVM appears to reduce weight loss, especially in pts with HNC (p = 0.058); however, no changes were documented regarding saliva characteristics and production, mucosal bleeding and voice properties. Evaluation of pain did not reveal differences between the groups (VAS 5.5 for the TV compared to VAS 6.2 for SM; p = 0.27) but the proportion of pts suffering from pain VAS≥7 differed between both populations (8% TV vs 23% SM; p = 0.043). There are no significant adverse events with TVM. Conclusions: TVM is safe and has therapeutic activity against OM. Further phase III study is needed to confirm these results.

No significant financial relationships to disclose.

Phase I trial of vorinostat in combination with erlotinib in advanced non-small cell lung cancer (NSCLC) patients with EGFR mutations after erlotinib progression

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Background: Vorinostat (SAHA) is a histone deacetylase inhibitor that induces differentiation, growth arrest and apoptosis of malignant cells. In vitro, there is a synergistic interaction of vorinostat in combination with gefitinib in NSCLC cell lines. Moreover, vorinostat increases levels of E-cadherin, p21, and downregulates expression of phospho-AKT and phospho-ERK1/2. These molecular findings could reverse resistance to erlotinib in mutant patients. Methods: We conducted a standard 3+3 Phase I trial of oral erlotinib 150 mg QD in combination with oral vorinostat (dose level 1 [DL1], 300 mg QD on days 1–7 every 21 days; DL2, 400 mg QD on days 1–7 every every 21 days, and; DL3, 400 mg QD on days 1–7 and 15–21 in a 28-day cycle). Cycles were repeated for a maximum of 6 cycles until progressive disease (PD) or intolerable toxicity. Pts with advanced NSCLC with EGFR mutations (Exon 19 and 21) after erlotinib progression and ECOG ≤2 were eligible. The main objectives were to determine the maximum tolerated dose (MTD), drug activity and safety of the combination regimen. Results: Thirteen patients have been enrolled up to date, with 9 patients available for this interim analysis (median age, 59 years; range 41–77). One patient (DL3 cohort) experienced a dose limiting toxicity (Grade 3 diarrhoea). The MTD has not been reached. The most common drug-related toxicities of any grade in the first cycle of treatment were anemia (77.8%), skin alterations (66.7%), diarrhoea (66.7%), xerostomy (55.6%), asymptomatic changes in liver function tests (55.6%), and asthenia (55.6%). There were no Grade ≥3 drug-related adverse events during first cycle of treatment and the global analysis of cycles showed asthenia (11.1%), somnolence (11.1%) and hyporexia (11.1%). Four pts discontinued treatment, all due to PD. Of 9 evaluable pts for efficacy, 6 had stable disease as best response (median duration of treatment 6.0 months, range 4–12). Final data will be presented at ASCO meeting. Conclusions: Although accrual continues to determine the MTD, the combination of vorinostat and erlotinib appears to be well tolerated and effective in this group of advanced NSCLC pts with EGFR mutations after erlotinib progression.

No significant financial relationships to disclose.

Survival of patients (pts) with advanced lung adenocarcinoma (ALA) treated in four hospitals from Bogotá D.C., Colombia, and report of a novel alteration in the epidermal growth factor receptor (EGFR) (ONCOLGroup study)

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Background: This study included 147 ALA pts treated between 2000 and 2007. Overall response rates (ORR), clinical benefit (CB), time to progression (TTP) and overall survival (OS) were estimated. EGFR E19 deletions were studied by length analysis fluorescently and the exon 21 L858R mutation by PCR Taqman assay. Results: Mean age was 66±12.8 years. Seventy- eight pts were women, 40% had never been exposed to tobacco smoke and PS was ≥70% in 119 pts. The brain was the dominant site for metastasis (38%) followed by the lungs (38%). Sixty-nine percent of the pts received a platinum doublet as first-line intervention and 32 pts (21.8%) had received erlotinib (E) as part of their treatment. Response to first-line treatment was available in 110 pts; ORR was 28%, CB 39% and TTP 4.2 mo. (range, 0.2–11). Second-line therapy was administered to 46 pts; ORR was 8%, CB 25% and TTP 3.7 mo. (range, 0.4–12). Twenty pts received third-line therapy, with an ORR of 35%, CB 50% and a TTP 3.9 mo. (range, 1.0–5.7). Median OS was 10.1 mo. (range, 6.3–19) and the PS, absence of tobacco exposure, and administration of E, positively influenced this outcome. EGFR mutational profile was assessed in 6 pts; 3 pts presented mutations in E19, one a 5-nucleotide deletion (E746_A750) and 2 pts had a 3 serine-rich nucleotide insertion (L747_S75) which has not been previously reported. The first patient had a partial response, and the last two, had survival greater than 16-mo. Conclusions: Outcomes for pts suffering from ALA in Colombia are similar to those described in other Latin American countries. Three pts with EGFR alterations were identified in this cohort; two presented a non- described change in E19 which may have corresponded to a novel alteration in our region, with possible increased sensitivity to E.

No significant financial relationships to disclose.

Trastuzumab (H) treatment in patients (pts) with metastatic breast cancer (MBC): An observational retrospective study in four hospitals from Bogotá, Colombia (ONCOLGroup study)

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Background: Breast cancer is the second most common cancer diagnosed in Colombian women, and approximately 26% of MBC are HER-2-positive in our population. The purpose of this study was to assess the characteristics and outcome of pts with HER-2-positive MBC treated with H-based therapy in Bogotá. Methods: This retrospective study included 119 pts treated between 2000 and 2007. Overall response rates (ORR), clinical benefit (CB), time to progression (TTP), and overall survival (OS) were estimated. Most common grade 2/3 toxicities are reported as well as variables that influenced survival. Results: Median age was 62 years (range, 37 to 75). Eighty-seven (73%) pts had recurrent disease and the rest had de novo MBC. Performance status was ≥70% in 114 pts, 66% had ≤2 metastatic sites, and 58% had hormone receptor positive disease. Previous adjuvant therapy before H included antracyclines in 68% and taxanes in 39% of the pts. H was part of the first-line therapy for MBC in 86.5% of the pts, leading to a 54% ORR in 103 evaluable pts. CB was 81% and median TTP was 6.1 months. (range, 1.2 to 26 mo). The most common toxicities in this setting included neutropenia ≥G3 (9%) and neuropathy ≥G3 (7%). H was given as part of second line therapy to 54 (45%) pts, but only 41 had evaluable disease. A 56% ORR was found in this subgroup, 85% CB and 4.7-month median of TTP. Grade ≥G3 hand-foot syndrome was the main toxicity (14%). Median OS after the diagnosis of MBC was 23 months (range, 1.6–93 mo), being longer for pts with HR-positive disease (p = 0.036), in pts with loco-regional relapse (p = 0.029), and in those older than 50 (p = 0.0025). Only two variables independently predicted OS: age (HR: 0.4, 95% CI: 0.35–0.93, p = 0.046) and HR status (HR: 0.7, 95% CI: 0.60–0.86, p = 0.040). Two pts (1.7%) had H-induced heart failure. Conclusions: H in combination with chemotherapeutic agents has been proved to be an effective and safe treatment for HER-2-positive MBC. The results from our series agreed with those reported in the medical literature and guarantee the regular use of H in Colombia.

No significant financial relationships to disclose.

Wood-smoke exposure (WSE) as a predictor of response and survival in erlotinib-treated advanced lung adenocarcinoma (ALA) patients (pts) (ONCOLGroup study)

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Background: There is consistent information suggesting that long-term WSE constitutes a risk factor for lung cancer. More than 50 years of WSE was associated with non-small cell lung cancer (NSCLC). In Colombia the prevalence of WSE in areas having less economic development is approximately 24%. The aim of the study was to evaluate WSE as a predictor of response and survival in ALA pts. Methods: This study included 168 pts with ALA treated between 2002 and 2007 in four referring hospitals of Bogotá. Retrospectively, we estimated overall response rates (ORR), time to progression (TTP) and overall survival (OS) in a subgroup of pts with significant WSE (exposure >5 years for at least 4 hours/day) treated with erlotinib, and compared them with the non-WSE population treated with the same compound. Results: Median age was 66 years (range, 29–96), 53% were female, 39% had never been smokers, 24% of all cohort pts had been considerably exposed to WS and 45 pts had received erlotinib during disease treatment (as 2nd or 3rd line). Sixteen of these pts (F11/M5, PS ≥70% 9 pts) had been exposed to WS and 29 not so (F17/M12, PS ≥70% 22 pts); 10 pts having WSE had been smoking for a mean of 14pk/yr history. ORR to erlotinib was 7% and 32% in pts with and without WSE respectively (p = 0.02). TTP was significantly higher in pts treated with erlotinib with no history of WSE (4.9 mo. vs 1.7 mo., p = 0.034). and in those who had received this compound as second-line (vs erlotinib used as third line, p = 0.044). Among pts with WSE history, OS was 6.6 mo. (range, 5.8–7.3) for those treated with Erlotinib and 12.7 mo. (range, 10.2–17) for those not treated with this compound (p = 0.04). Multivariate analysis was carried out for determining the factors influencing mortality between pts with WSE; only PS (HR: 4.6, 95%CI: 1.2–29, p = 0.050) and gender (HR: 3.6, 95%CI: 2.7–18, p = 0.036) were significant. Conclusions: WSE was associated with a poorer response and survival in ALA pts treated with erlotinib in Colombia.

No significant financial relationships to disclose.

Myelophthisis in solid tumors: Old aspects, new concepts (ONCOLGroup study)

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Background: Myelophthisis is a form of bone marrow failure due to replacement of hematopoietic tissue by abnormal tissue, most commonly metastatic carcinomas. This results in extramedullary hematopoiesis, typically in the spleen leading to premature release of hematopoietic cells into the circulation. Peripheral blood findings of myelophthisis may include nucleated red blood cells, tear drop forms, giant platelets, and immature leukocytes. Overall, this picture is usually called leukoerythroblastosis. Methods: This retrospective study included 89 patients (pts) with solid tumors and myelophtisis that had been treated from 1991 to 2006 in a single reference center in Bogotá. We made a detailed analysis of pts characteristics and outcomes. Results: Mean age was 47.5±17.2 years, there was homogeneous gender distribution (F46/M43) and 62% pts had a PS ≥60%. Twenty-seven pts (30%) had breast cancer, pathology followed by primary unknown tumours (21%), rabdomiosarcoma (10%), prostate adenocarcinoma (10%), gastric carcinoma (7%) and others (22%). At the time when myelophtisis was documented 72% and 50% of pts had osseous and visceral metastasis respectively; 81 pts presented anaemia (Hb 9.8 ± 1.2 gr/dl), mean platelet count was 174,000 and mean leukocyte count was 24,283 ± 5,447. Forty-three pts received chemotherapy following the diagnosis of medullar infiltration, and normal leukocyte count was being seen in 40% of them after such treatment. Nine episodes of febrile neutropenia were found; median overall survival (OS) following the diagnosis of neoplasia and myelophtisis were 13.8 months and 2.2 months respectively. The factors related to lower survival rate were the presence of Hb ≤8.5 gr/dl (HR: 0,54, CI95% 0,32–0,95; p = 0.04), >3 metastasis sites (HR: 0,67, CI95% 0,45–0,92; p = 0.03), visceral disease (HR: 0,72, CI95% 0,66–0,89; p = 0.04) and febrile neutropenia caused by chemotherapy (HR: 0,52, CI95% 0,37–0,60; p = 0.02). Conclusions: Myelophtisis is a serious condition modifying the OS of patients having solid tumours. Treatment for this subgroup should be selected bearing in mind its potential haematological toxicity.

No significant financial relationships to disclose.

Palliative endobronchial brachytherapy for non-small cell lung cancer

BACKGROUND

Non-small cell lung cancers (NSCLC) constitutes about 80% of all lung cancer cases. Although surgery is the only curative treatment of NSCLC, fewer than 20% of tumors can be radically resected. Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Endobronchial brachytherapy (EBB) has been used as one approach to improve local control either alone or in combination with other treatments.

OBJECTIVES

To assess the effectiveness of palliative EBB in increasing survival and to control thoracic symptoms in patients with advanced NSCLC compared with external beam radiation therapy (EBRT) or other alternative endoluminal treatments.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other databases were searched, as were reference lists and handsearching of selected journals and conference proceedings.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing different regimens of palliative EBB with EBRT or other endobronchial interventions in patients with advanced NSCLC.

DATA COLLECTION AND ANALYSIS

Thirteen RCTs were included. There were important differences in the doses of radiotherapy investigated, patient characteristics and the outcomes measured. Because of this heterogeneity no meta-analysis was attempted.

MAIN RESULTS

We found trials comparing EBB to EBRT alone, EBB plus EBRT to EBRT alone, EBB plus chemotherapy to EBB alone, EBB to Nd-YAG laser and comparisons between diverse fractionation schedules of high dose rate EBB. From the heterogeneous information obtained from several small RCTs, we concluded that EBRT alone is more effective for palliation of NSCLC symptoms than EBB alone. Our findings did not provide conclusive evidence to recommend EBB plus EBRT to relieve symptoms compared to EBRT alone. Overall, for the primary endpoint of survival there was no evidence of benefit for EBB compared to EBRT and Nd-YAG laser or for the combination of EBB with chemotherapy. Additionally, findings from one trial suggested that twice 7.4 Gy was superior to the four times per week 3.8 Gy schedule for mean time of local control and fatal haemoptysis. No significant differences were found for fatal haemoptysis as an adverse event of EBB.

AUTHORS' CONCLUSIONS

The evidence did not provide conclusive results that EBB plus EBRT improved symptom relief over EBRT alone. We were not able to provide conclusive evidence to recommend EBB with EBRT, chemotherapy or Nd-YAG laser. For patients previously treated by EBRT who are symptomatic from recurrent endobronchial central obstruction, EBB may be considered in selected cases.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common, expensive and frequently fatal condition. There is an urgent need for developing new therapies to further reduce severe sepsis-induced mortality. One of those approaches is the use of human recombinant activated protein C (APC).

OBJECTIVES

We assessed the clinical effectiveness of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 2); MEDLINE (1966 to 2005); EMBASE (1980 to 2005) and LILACS (1982 to 2005). We contacted researchers and organizations working in the field. We did not have any language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, quality assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I-squared (I(2)). We used a random-effects model.

MAIN RESULTS

We included four studies involving 4911 participants (4434 adults and 477 paediatric patients). For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.92, 95% confidence interval (CI) 0.72 to 1.18; P = 0.50, I(2) = 72%). The effectiveness of APC did not seem to be associated with the degree of severity of sepsis (two studies): for an APACHE II score less than 25 the RR was 1.04 (95% CI 0.89 to 1.21; P = 0.70), and in participants with an APACHE II score of 25 or more the RR was 0.90 (95% CI 0.54 to 1.49; P = 0.68). APC use was, however, associated with a higher risk of bleeding (RR 1.48 (95% CI 1.07 to 2.06; P = 0.02, I(2) = 8%). Two studies were stopped early because there was little chance of reaching the efficacy endpoint by completion of the trial.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC seems to be associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common, expensive and frequently fatal condition. There is an urgent need for developing new therapies to further reduce severe sepsis-induced mortality. One of those approaches is the use of human recombinant activated protein C (APC).

OBJECTIVES

We assessed the clinical effectiveness of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 2); MEDLINE (1966 to 2005); EMBASE (1980 to 2005) and LILACS (1982 to 2005). We contacted researchers and organizations working in the field. We did not have any language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded neonates.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, quality assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I-squared (I(2)). We used a random-effects model.

MAIN RESULTS

We included four studies involving 4911 participants (4434 adults and 477 paediatric patients). For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.92, 95% confidence interval (CI) 0.72 to 1.18; P = 0.50, I(2) = 72%). The effectiveness of APC did not seem to be associated with the degree of severity of sepsis (two studies): for an APACHE II score less than 25 the RR was 1.04 (95% CI 0.89 to 1.21; P = 0.70), and in participants with an APACHE II score of 25 or more the RR was 0.90 (95% CI 0.54 to 1.49; P = 0.68). APC use was, however, associated with a higher risk of bleeding (RR 1.48 (95% CI 1.07 to 2.06; P = 0.02, I(2) = 8%). Two studies were stopped early because there was little chance of reaching the efficacy endpoint by completion of the trial.

AUTHORS' CONCLUSIONS

This review suggests that APC should not be used in sepsis with an APACHE II score of less than 25 or, in paediatric patients. There is very weak evidence supporting APC use in patients with severe sepsis and at high-risk of death. As a result, policy-makers, clinicians and academics should be cautious when promoting the use of APC to patients with severe sepsis and an APACHE II score of 25 or greater. There is a need for further RCTs to answer with certainty what the role of APC is for patients with severe sepsis and an APACHE II score of at least 25. Those RCTs should be designed and conducted by non-profit organizations.

Antibiotics for acute laryngitis in adults

BACKGROUND

Acute laryngitis is a common illness worldwide. Diagnosis is often made by case history alone and treatment is often directed towards controlling symptoms.

OBJECTIVES

The aim of this review was to assess the effectiveness of different antibiotic therapies in adults suffering acute laryngitis. A secondary objective was to report the rates of adverse events associated with these treatments.

SEARCH STRATEGY

We systematically screened the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2006); MEDLINE (January 1966 to December Week 2 2006); and EMBASE (1974 to June 2006), LILACS (from 1982 to December 2006 ) and BIOSIS (1980 to June 2002). Other strategies included hand searching relevant journals, searching ongoing trial databases and general databases such as Google scholar.

SELECTION CRITERIA

Randomized controlled trials comparing any antibiotic therapy with placebo in acute laryngitis. The main outcome measurement was objective voice scores.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two review authors and then descriptively synthesized.

MAIN RESULTS

Only two trials met study inclusion criteria after extensive literature searches. One hundred participants were randomly selected to receive either penicillin V (800 mg twice a day for five days), or an identical placebo, in a study of penicillin V in acute laryngitis in adults. A tape recording of each patient reading a standardized text was obtained during the first visit, subsequently during re-examination after one and two weeks, and at follow up after two to six months. No significant differences were found between the groups. The trial also measured symptoms reported by participants and found no significant differences. The second trial investigated erythromycin for treating acute laryngitis in 106 adults. The mean objective voice scores measured at the first visit, at re-examination after one and two weeks, and at follow up after two to six months did not significantly differ between control and intervention groups. At one week there were significant beneficial differences in the severity of reported vocal symptoms as judged by the participants (P = 0.042). Comparing the erythromycin and placebo groups on subjective voice scores the a priori relative risk (RR) was 0.7 (95% confidence interval (CI) 0.51 to 0.96, P = 0.034) and the number needed to treat (NNT) was 4.5.

AUTHORS' CONCLUSIONS

Antibiotics appear to have no benefit in treating acute laryngitis. Erythromycin could reduce voice disturbance at one week and cough at two weeks when measured subjectively. We consider that these outcomes are not relevant in clinical practice. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.

Interventions for treating AIDS-associated Hodgkin s lymphoma in treatment-naive adults

BACKGROUND

Hodgkin's disease (HD) is the most common non-AIDS-defining malignancy in HIV-infected patients. Its unusually aggressive tumour behaviour includes a higher frequency of unfavourable histologic subtypes, high-stage and extranodal involvement by the time of presentation (anal canal, stomach), and poor therapeutic outcome, in comparison with HD outside the HIV setting. The optimal therapeutic strategy is still controversial, and median overall survival is short, ranging from 12 to 18 months. Thus, there is a need to identify the efficacy and safety of different interventions for AIDS-associated HD on overall survival and disease-free survival in treatment-naive adults with AIDS.

OBJECTIVES

To assess the effects of different interventions for treating AIDS-associated Hodgkin's disease including chemotherapy, bone marrow transplantation (BMT), and gene therapy on overall survival and disease-free survival in treatment-naive adults with AIDS.

SEARCH STRATEGY

We searched The Cochrane HIV/AIDS Group Trials Register (September 2006), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2006), MEDLINE (1966 to September 2006), EMBASE (1974 to September 2006) LILACS (1982 to September 2006), ISI Web of Knowledge (1993 to September 2006), and AIDSearch (1980 to December 2006). Date of most recent search: December 2006.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies, but no eligible randomised controlled trials were identified.

MAIN RESULTS

We were unable to find any randomised controlled trials of interventions for treating AIDS-associated HD in treatment-naive adults with AIDS.

AUTHORS' CONCLUSIONS

Randomised controlled trials are needed to establish the efficacy and safety of interventions for treating AIDS-associated HD in treatment-naive adults with AIDS.

Antibiotics for acute laryngitis in adults

BACKGROUND

Acute laryngitis is a common illness worldwide. Diagnosis is often made by case history alone and treatment is often directed towards controlling symptoms.

OBJECTIVES

The aim of this review was to assess the effectiveness of different antibiotic therapies in adults suffering acute laryngitis. A secondary objective was to report the rates of adverse events associated with these treatments.

SEARCH STRATEGY

We systematically screened the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004); MEDLINE (January 1966 to June Week 3 2004); and EMBASE (1974 to June 2004), LILACS (from 1982 to the 40th edition) and BIOSIS (1980 to June 2002). Other strategies included hand searching relevant journals, searching ongoing trial databases and general databases such as Alta Vista.

SELECTION CRITERIA

Randomized controlled trials comparing any antibiotic therapy with placebo in acute laryngitis. The main outcome measurement was objective voice scores.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two people and then descriptively synthesised.

MAIN RESULTS

Only two trials met study inclusion criteria after extensive literature searches. One hundred patients were randomly selected to receive either penicillin V (800 mg twice a day for five days), or an identical placebo, in a study of penicillin V in acute laryngitis in adults. A tape recording of each patient reading a standardised text was obtained during the first visit, subsequently during re-examination after one and two weeks, and at follow up after two to six months. No significant differences were found between the groups. The trial also measured symptoms reported by patients and found no significant differences. The second trial investigated erythromycin for treating acute laryngitis in 106 adults. The mean objective voice scores measured at the first visit, at re-examination after one and two weeks, and at follow up after two to six months did not significantly differ between control and intervention groups. At one week there were significant beneficial differences in the severity of reported vocal symptoms as judged by the patients (p = 0.042). Comparing the erythromycin and placebo groups on subjective voice scores the a priori relative risk (RR) was 0.7 (95% confidence interval (CI) 0.51 to 0.96, p = 0.034) and the number needed to treat (NNT) was 4.5.

AUTHORS' CONCLUSIONS

Antibiotics appear to have no benefit in treating acute laryngitis. Erythromycin could reduce voice disturbance at one week and cough at two weeks when measured subjectively. We consider that these outcomes are not relevant in clinical practice. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.

[Effectiveness of flunarizine in the prophylaxis of migraine: a meta-analytical review of the literature]

BACKGROUND

Migraine is a common and disabling health problem among young and middle aged adults. Flunarizine have been used as a prophylactic medication in its management for more than two decades.

OBJECTIVE

The aim of the study is to systematically review the evidence obtained from randomized controlled trials about the efficacy and security of flunarizine versus placebo for the prevention of migraine in adults.

MATERIALS AND METHODS

Electronic search were performed using the databases MEDLINE, EMBASE, Biosis, the Cochrane Library, Lilacs and others. Reference lists of retrieved studies, reviews and conference abstracts were used to found another articles. Additionally, the authors performed a handsearched in recognized journals related to migraine and neurological topics. Randomized, placebo controlled, double blind trials assessing the efficacy of flunarizine for preventing migraine were included. We evaluated the frequency of the attacks by comparing the mean frequency before and after the intervention for each group of treatment and then the two groups were compared. To evaluate the security of flunarizine we used included and excluded studies and open trials.

RESULTS

Nine studies were obtained but only four met the inclusion criteria. The fixed effects model reported a reduction in the frequency of attacks by using flunarizine. The monthly difference was 0.55 attacks (CI 95%= 0.215 0.895; p= 0.002). Somnolence was the most frequent adverse effect in 20.5% of the subjects (n= 1,987).

CONCLUSIONS

Based on a small number of trials, flunarizine, at a daily dose of 10 mg lightly reduces the frequency of migraine attacks.