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Rainess R, Campbell P, Santamala J, Kubin CJ, Mehta M. Outcomes Associated with De-escalation of Antibiotics to Target Positive Cultures when Treating Febrile Neutropenia. J Pharm Pract 2024; 37:301-306. [PMID: 36201023 DOI: 10.1177/08971900221132120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Patients with hematologic malignancies frequently develop febrile neutropenia (FN) and subsequently receive long courses of broad-spectrum antibiotics. Limited data is available on de-escalation strategies. Methods: This was a retrospective observational cohort study of adult patients with a hematologic malignancy, FN, and positive culture results from June 2017 to June 2020. A conventional group (patients who remained on empiric, broad-spectrum agents) was compared to a de-escalation group (patients whose antibiotic therapy was de-escalated based on culture results). The primary outcome was the incidence of recurrent fever or antibiotic escalation due to infection while neutropenic. Results: Of the 123 patients included, the composite primary outcome occurred in 35.3% in the de-escalation group and 39.3% in the conventional group (P = .83). For secondary outcomes, median time to recurrent fever was 7 days in the de-escalation group and 7 days in the conventional group (P = .73). Incidence of Clostridioides difficile was 5.9% in the de-escalation group and 6.7% in the conventional group (P = 1.00). Development of multidrug resistant pathogens during hospital admission was 20.6% in the de-escalation group and 14.6% in the conventional group (P = .59). Median length of broad-spectrum antibiotics was 3 days in the de-escalation group and 8 days in the conventional group (P < .001). All-cause mortality within 30 days was 0 in the de-escalation group and 5.6% in the conventional group (P = .32). Conclusion: In a small sample of patients with a hematologic malignancy and FN, de-escalating antibiotics based on positive cultures decreased the duration of antibiotic therapy without increasing the rate of antibiotic failure.
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Affiliation(s)
- Rebecca Rainess
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Campbell
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer Santamala
- Department of Pharmacy, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Christine J Kubin
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Monica Mehta
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
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2
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Riggenbach E, Waser M, Mueller SA, Aebersold DM, Giger R, Elicin O. Oncologic outcome with versus without target volume compartmentalization in postoperative radiotherapy for oral cavity squamous cell carcinoma. Front Oncol 2024; 14:1362025. [PMID: 38590644 PMCID: PMC10999524 DOI: 10.3389/fonc.2024.1362025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
Background and purpose The volume treated with postoperative radiation therapy (PORT) in patients with oral cavity squamous cell carcinoma (OCSCC) is a mediator of toxicity affecting quality of life. Current guidelines only allow for very limited reduction of PORT volumes. This study investigated the safety and efficacy of de-intensified PORT for patients with OCSCC by refined compartmentalization of the treatment volume. Materials and methods This retrospective cohort study identified 103 OCSCC patients treated surgically from 2014 to 2019 with a loco-regional risk profile qualifying for PORT according to guidelines. PORT was administered only to the at-risk compartment and according to a refined compartmentalization concept (CC). Oncological outcome of this CC cohort was compared to a historical cohort (HC) of 98 patients treated before the CC was implemented. Results Median follow-up time was 4.5 and 4.8 years in the CC and HC cohorts, respectively. In the CC cohort, a total of 72 of 103 patients (70%) had a pathological risk profile that allowed for further compartmentalization and, hence, received a reduced treatment volume or omission of PORT altogether. Loco-regional control at 3 and 5 years was 77% and 73% in the CC cohort versus 78% and 73% in the HC (p = 0.93), progression-free survival was 72% and 64% versus75% and 68% (p = 0.58), respectively. Similarly, no statistically significant difference was seen in other outcome measures. Conclusions De-intensified PORT limiting the treatment volume to the at-risk compartment or avoiding PORT altogether for low-risk patients with OCSCC does not seem to compromise disease control in this retrospective comparison. Based on these hypothesis-generating findings, a prospective study is being planned.
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Affiliation(s)
- Elena Riggenbach
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Manuel Waser
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon A. Mueller
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital and University of Zurich, Zurich, Switzerland
| | - Daniel M. Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Baker B, Hung F, Smith MJ, Erkanli A, Greenhill K, Hayes J, Parish A, Zhou G, Moorthy GS, Deri CR. Utility of methicillin-resistant Staphylococcus aureus nasal PCR testing in pediatric patients with suspected respiratory infections. J Pediatric Infect Dis Soc 2024:piae023. [PMID: 38466576 DOI: 10.1093/jpids/piae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 03/13/2024]
Abstract
Observational studies in adults suggest nasal methicillin-resistant Staphylococcus aureus (MRSA) swabs have a high negative predictive value (NPV) for ruling out MRSA pneumonia, however pediatric data are limited. This retrospective study of 505 pediatric patients found a 99.8% NPV among children with suspected respiratory infections.
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Affiliation(s)
- Brooke Baker
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Frances Hung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael J Smith
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine Greenhill
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Jillian Hayes
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Grace Zhou
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ganga S Moorthy
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Saito N, Tsuchiya J, Itoga M, Okamura Y, Tsuyama H, Kimura M, Inoue F, Kimura T, Ozaki H, Tono Y, Minakawa S, Tomita H. Multiple Blood Culture Sampling, Proper Antimicrobial Choice, and Adequate Dose in Definitive Therapy Supported by the Antimicrobial Stewardship Team Could Decrease 30-Day Sepsis Mortality Rates. Infect Drug Resist 2024; 17:207-219. [PMID: 38283110 PMCID: PMC10812706 DOI: 10.2147/idr.s445917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024] Open
Abstract
Objective This study aimed to identify factors that should be focused on by the antimicrobial stewardship team for treating patients with sepsis, by investigating the mortality of patients with sepsis within 30 days and the mortality-related factors in our hospital over a 10-year period from the perspective of appropriate antimicrobial use. Methods Factors associated with 30-day mortality were investigated using hierarchical multiple logistic regression in 1406 patients with pathogen-identified sepsis in Hirosaki University Hospital. These factors were clinical data, microbiological data, antimicrobials used in empiric and definitive therapies, presence/absence of ineffective use, underdosing as evaluated using Monte Carlo simulation, and practice of de-escalation. Results The ineffective use of antimicrobials in empiric therapy and the underdosing and ineffective use in definitive therapy were significantly associated with 30-day mortality (odds ratio [OR] = 2.70, 3.72, and 3.65, respectively). Multiple blood culture sampling was inversely associated with these inappropriate antimicrobial uses. Every year, the 30-day mortality rate has been decreasing, in line with the increase in multiple blood culture sampling and de-escalation; the inappropriate use of antimicrobials has also decreased. Conclusion Multiple blood culture sampling, proper choice of antimicrobial, and using an adequate dose in definitive therapy could decrease the 30-day mortality rate in patients with sepsis and these factors could be supported by the antimicrobial stewardship team.
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Affiliation(s)
- Norihiro Saito
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Junichiro Tsuchiya
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masamichi Itoga
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuji Okamura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromasa Tsuyama
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masahiko Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Fumio Inoue
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Toshiyuki Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromi Ozaki
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Yuka Tono
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Satoko Minakawa
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hirofumi Tomita
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Castagnini F, Pardo F, Lucchini S, Rotini M, Cavalieri B, Dalla Rosa M, Vitacca S, Di Martino A, Faldini C, Traina F. Cementless Primary Stems in Revision Hip Arthroplasty: A Narrative Review. J Clin Med 2024; 13:604. [PMID: 38276110 PMCID: PMC10816713 DOI: 10.3390/jcm13020604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Cementless primary stems in revision hip arthroplasties may be conservative options to preserve bone stock and provide adequate reconstruction of the hip biomechanics. However, there is still little evidence about indications, limitations, and outcomes. This narrative review showed that conventional standard stems were adopted in different revision settings, up to Paprosky IIIA grade bone defects. In cases of acceptable metaphyseal bone stock, when a scratch fit of at least 4 cm can be achieved, a conventional cementless stem may be an adequate solution. Mid-term clinical and radiographic outcomes and survival rates were similar to long revision stems, whereas complications, surgical time, and costs were lower among conventional stems. However, unsuitable contexts for conventional stems included canal diameters larger than 18 mm and failed revision stems with cortical weakening. Even short stems can be considered in revisions, in order to preserve bone stock and stay proximal to femoral remodeling zones and bone/cement plugs. Short stems were successfully adopted up to Paprosky IIIA bone defects, achieving mid-term survival rates not inferior to long revision stems. Ageing, osteoporosis, and intraoperative femoral fractures were the main negative prognostic factors. In very select cases, a downsizing technique (from longer to shorter stems) may be adopted to simplify the procedure and reduce complications.
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Affiliation(s)
- Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Francesco Pardo
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Stefano Lucchini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Marco Rotini
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Bruno Cavalieri
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Mattia Dalla Rosa
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Stefano Vitacca
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
| | - Alberto Di Martino
- 1 Orthopedics and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (A.D.M.); (C.F.)
- Department of Biomedical and Neuromotor Sciences—DIBINEM, University of Bologna, 40126 Bologna, Italy
| | - Cesare Faldini
- 1 Orthopedics and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (A.D.M.); (C.F.)
- Department of Biomedical and Neuromotor Sciences—DIBINEM, University of Bologna, 40126 Bologna, Italy
| | - Francesco Traina
- Ortopedia-Traumatologia e Chirurgia Protesica e dei Reimpianti d’Anca e di Ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy; (F.P.); (S.L.); (M.R.); (B.C.); (M.D.R.); (S.V.); (F.T.)
- Department of Biomedical and Neuromotor Sciences—DIBINEM, University of Bologna, 40126 Bologna, Italy
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Nieto-Tous M, Diaz-Martinez A, De-Arriba-García M, Roca-Prats A, Monfort-Beltrán S, Ivañez-Muñoz M, Alberola-Rubio J, Perales A, Monfort-Ortiz R. GESTACOVID Project: Psychological and Perinatal Effects in Spanish Pregnant Women Subjected to Strict Confinement Due to the COVID-19 Pandemic and Their Evolution during De-Escalation. J Clin Med 2023; 13:248. [PMID: 38202254 PMCID: PMC10779534 DOI: 10.3390/jcm13010248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
The lockdown and de-escalation process following the COVID-19 pandemic led to a period of new normality. This study aimed to assess the confinement impact on the mental health of peripartum women, as their psychological well-being may be particularly vulnerable and thus affect their offspring's development. A cross-sectional epidemiological study was conducted among women who gave birth during strict confinement (G0) and the new normality period (G1), in which a self-administered paper-based questionnaire assessed 15 contextual factors and the General Health Questionnaire-12 (GHQ-12). For each item, it was verified whether the positive screening rate differed in each confinement phase, and a risk factor study was conducted. For G0, significantly higher positive screening and preterm birth rates were observed in the positive screening group. In the case of G1, maternal age (>35 years), decreased physical activity, and normal weight were found to be protective factors against distress. This study underscores the heightened mental health risk for postpartum women during major psychosocial upheavals (war, economic crisis, natural disasters, or pandemics), along with their resilience as the positive screening rate decreases with the new normality. Findings encourage adopting strategies to identify high-risk women and promote effective measures, such as promoting physical activity.
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Affiliation(s)
- Mar Nieto-Tous
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
| | - Alba Diaz-Martinez
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, 46022 Valencia, Spain
| | | | - Alba Roca-Prats
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
| | - Sara Monfort-Beltrán
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
| | - María Ivañez-Muñoz
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
| | - José Alberola-Rubio
- Instituto de Investigación Sanitaria La Fe de Valencia, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | - Alfredo Perales
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
- Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universitat de València, 46010 Valencia, Spain
| | - Rogelio Monfort-Ortiz
- Departmento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain (R.M.-O.)
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Tvedskov TF. Axillary surgery in oncologic breast surgery: a narrative review. Gland Surg 2023; 12:1774-1785. [PMID: 38229843 PMCID: PMC10788576 DOI: 10.21037/gs-23-362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
Background and Objective With the improved survival for breast cancer there is now an increased focus on quality of life after treatment. Axillary surgery is known to be associated with significant risk of arm morbidity feared by the patients, and several studies have shown de-escalation is possible in different settings. In this review, an overview will be given on new techniques and procedures for de-escalation of axillary surgery in breast cancer patients and the subsequent implications for adjuvant systemic treatment. Methods This study is a narrative review. PubMed was searched for relevant publications in English published between January 2018-June 2023. Only publications with major impact on clinical practice have been included with main emphasis on meta-analysis. In addition, Clinicaltrial.gov has been searched for on-going studies. Key Content and Findings New tracer techniques are described as well as the on-going reduction in axillary lymph node dissection (ALND) at primary surgery even in node positive patients, and the axillary staging possibilities after down-staging of the axilla by neoadjuvant treatment. Finally axillary staging at local recurrence and in case of ductal carcinoma in situ is described. Conclusions ALND is no longer routinely recommended in many node positive patients and further de-escalation is investigated. The lack of knowledge on precise axillary status will require cooperating studies between oncologists and breast surgeons in order to avoid escalation of systemic treatment due to the lack of applicability of trial eligibility criteria. Furthermore, investigations on the use of axillary imaging for staging are needed.
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8
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Ofri A, Elstner K, Mann GB, Kumar S, Warrier S. Neoadjuvant chemotherapy in non-metastatic breast cancer: The surgeon's perspective. Surgeon 2023; 21:356-360. [PMID: 37088639 DOI: 10.1016/j.surge.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/25/2023]
Abstract
Breast cancer is the most common non-skin cancer in Australia, affecting 1 in 7 women by the age of 85 years. Current management of early breast cancer is becoming increasingly variable and complex. The typical range of treatments include some combination of surgery, chemotherapy and targeted therapy, immunotherapy, radiotherapy, and endocrine therapy. Neoadjuvant chemotherapy (NACT) in carefully selected patients can facilitate increased rates of breast conservation therapy, and when successful, offers improved cosmesis due to less extensive resection of tissue. A neoadjuvant approach also provides biological insight into a patient's tumour, prognostication based on a patient's response to therapy, as well as enabling their treating oncologist to personalise adjuvant strategies based on the presence or absence of residual cancer at surgery. Neoadjuvant chemotherapy has become an integral element in the provision of breast conserving surgery to selected early-stage breast cancer patients. Appreciating the indications and understanding the likely outcomes from NACT in select situations, can result in significant improvements in patient tailored care.
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Affiliation(s)
- A Ofri
- Department of Surgery, Mater Hospital, North Sydney NSW 2060, Australia; St Vincent's Clinical School, University of New South Wales, Sydney NSW 2052, Australia; Royal Prince Alfred Hospital Institute of Academic Surgery, Camperdown NSW 2050, Australia.
| | - K Elstner
- Department of Breast Services, Monash Health, Bentleigh East VIC 3165, Australia
| | - G B Mann
- Department of Surgery, The University of Melbourne, Parkville, VIC 3052, Australia
| | - S Kumar
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown NSW 2050, Australia; Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead NSW 2145, Australia; Westmead Breast Cancer Institute, Westmead Hospital, Westmead, NSW 2145, Australia
| | - S Warrier
- Royal Prince Alfred Hospital Institute of Academic Surgery, Camperdown NSW 2050, Australia; Department of Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown NSW 2050, Australia
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9
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Gisbert JP, Chaparro M. De-escalation of biological treatment in inflammatory bowel disease: A comprehensive review. J Crohns Colitis 2023:jjad181. [PMID: 37943286 DOI: 10.1093/ecco-jcc/jjad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Biological therapy is an effective treatment for inflammatory bowel disease (IBD). However, due to cost and safety concerns, after achieving remission, dose de-escalation strategies have been suggested. AIM To critically review available data on dose de-escalation of biologics (or other advanced therapies) in IBD. We will focus on studies evaluating de-escalation to standard dosing in patients initially optimised, and also on studies assessing de-escalation from standard dosing. METHODS A systematic bibliographic search was performed. RESULTS The mean frequency of de-escalation after previous dose intensification (12 studies, 1,474 patients) was 34%. The corresponding frequency of de-escalation from standard dosing (5 studies, 3,842 patients) was 4.2%. The relapse rate of IBD following anti-TNF de-escalation to standard dosing in patients initially dose-escalated (10 studies, 301 patients) was 30%. The corresponding relapse rate following anti-TNF de-escalation from standard dosing (9 studies, 494 patients) was 38%. The risk of relapse was lower for patients in clinical, biologic, and endoscopic/radiologic remission at the time of de-escalation. A role of anti-TNF therapeutic drug monitoring in the decision to dose de-escalate has been demonstrated. In patients relapsing after de-escalation, re-escalation is generally effective. De-escalation is not consistently associated with a better safety profile. The cost-effectiveness of the de-escalation strategy remains uncertain. Finally, there is not enough evidence to recommend dose de-escalation of biologics different from anti-TNFs or small molecules. CONCLUSIONS Any consideration for de-escalation of biological therapy in IBD must be tailored, taking into account the risks and consequences of a flare and patients' preferences.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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10
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Fujisaki T, Kuno T, Iwagami M, Miyamoto Y, Takagi H, Deharo P, Cuisset T, Briasoulis A, Panaich S, Latib A, Kohsaka S. Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2023; 102:788-802. [PMID: 37675959 DOI: 10.1002/ccd.30811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients. METHODS PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding. RESULTS Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies. CONCLUSIONS Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
- Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | | | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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de Nonneville A, Boudin L, Houvenaeghel G, Gonçalves A, Bertucci F. A machine learning-based algorithm to eliminate breast and axillary surgery in patients with breast cancer and pathological complete response after neoadjuvant chemotherapy. Ann Transl Med 2023; 11:397. [PMID: 37970604 PMCID: PMC10632564 DOI: 10.21037/atm-23-689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/22/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Alexandre de Nonneville
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Laurys Boudin
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Gilles Houvenaeghel
- Department of Surgical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Anthony Gonçalves
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - François Bertucci
- Laboratory of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli-Calmettes, INSERM UMR1068, CNRS UMR725, Equipe Labellisée Ligue Nationale Contre Le Cancer, Marseille, France
- Department of Medical Oncology, CRCM, Institut Paoli‑Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
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Socha J, Senkus E. Is radiotherapy after primary chemotherapy (RAPCHEM) on the right path to de-escalation? Ann Transl Med 2023; 11:396. [PMID: 37970611 PMCID: PMC10632575 DOI: 10.21037/atm-23-549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/17/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine – National Research Institute, Warsaw, Poland
- Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland
| | - Elżbieta Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
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Capodanno D, Greco A. Short Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months? JACC Cardiovasc Interv 2023; 16:2511-2513. [PMID: 37804285 DOI: 10.1016/j.jcin.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy.
| | - Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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15
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Sato J, Kodaira M, Harada H, Iguchi H, Yoshida T, Shibata H. Efficacy and safety of bone management agents administered at 12 weeks vs. 4 weeks in patients with bone metastases: A systematic review. J Oncol Pharm Pract 2023:10781552231203720. [PMID: 37807836 DOI: 10.1177/10781552231203720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Bone modifying agents (BMAs) have been used to prevent skeletal-related events (SRE) in cancer patients with bone metastases. In this meta-analysis, efficacy and adverse events (AEs) were studied based on a de-escalation strategy in which the BMA dosing interval was prolonged from 4 to 12 weeks. METHODS PubMed, Cochrane, ICHUSHI, and CINAHL were searched for articles on BMA dosing intervals from outcomes measured were the incidence of SRE and related various AEs. A quantitative meta-analysis was performed using a random-effects model to calculate relative risk ratios (RRs) and 95% confidence intervals (CIs). RESULT The meta-analysis included three randomized controlled studies (RCTs) of Zoledronic acid hydrate (ZA) (n = 2663) and six RCTs (n = 141) on BMA other than ZA. There was no difference in the incidence of SREs when comparing the dosing frequency of 12 versus 4 weeks for BMA (RR = 1.21, 95% CI [0.82-1.78], p = 0.33). Further, AEs related to treatment discontinuation were significantly less frequent with ZA given every 12 weeks than when given every 4 weeks (RR = 0.51 [0.30-0.89], p = 0.02). In particular, renal dysfunction leading to grade ≥3 or discontinuation of treatment with ZA occurred significantly less frequently with every 12-week dosing (RR = 0.33 [0.12-0.91], p = 0.33). CONCLUSION This meta-analysis showed no influence of BMA de-escalation on the incidence of SRE; nevertheless, AEs appeared to reduce with the de-escalated usage of ZA.
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Affiliation(s)
- Junya Sato
- Faculty of Pharmaceutical Sciences, Shonan University of Medical Sciences, Yokohama, Japan
| | | | - Hiroyuki Harada
- Division of Oral Health Sciences, Department of Oral and Maxillofacial Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Japan
| | | | - Taichi Yoshida
- Department of Clinical Oncology, Akita University Graduate School of Medicine, Akita, Japan
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Banini M, Visani L, Livi L, Meattini I. De-escalating postoperative radiation therapy after primary systemic therapy in cT1-2N1 breast cancer: lesson from the RAPCHEM/BOOG 2010-03 trial. Ann Transl Med 2023; 11:366. [PMID: 37675297 PMCID: PMC10477657 DOI: 10.21037/atm-23-1051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Marco Banini
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Luca Visani
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Debien V, Adam V, Coart E, Agostinetto E, Goulioti T, Molinelli C, Arahmani A, Zoppoli G, Piccart M. DECRESCENDO: de-escalating chemotherapy in HER2-positive, estrogen receptor-negative, node-negative early breast cancer. Future Oncol 2023; 19:1655-1667. [PMID: 37609714 DOI: 10.2217/fon-2022-1282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
The human epidermal growth factor receptor 2 (HER2)-enriched intrinsic subtype represents up to 75% of all HER2-positive hormone receptor (HR)-negative breast cancer (BC). Optimizing HER2-targeting therapy in this population might allow the omission of anthracycline-based chemotherapy, which is associated with potentially severe toxicities. DECRESCENDO (NCT04675827) is a large, multicenter, single-arm phase II trial in patients with HR-negative, HER2-positive, node-negative early BC evaluating a neoadjuvant pertuzumab and trastuzumab fixed-dose combination administered subcutaneously plus taxane-based chemotherapy followed by adjuvant treatment, adapted according to response to neoadjuvant therapy. The primary end point is the 3-year recurrence-free survival rate in patients with 'HER2-enriched' tumors and a pathological complete response. This flexible care substudy offers adjuvant treatment administration outside the hospital to some patients.
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Affiliation(s)
- Véronique Debien
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | | | - Elisa Agostinetto
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | - Chiara Molinelli
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | - Gabriele Zoppoli
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Parma, Department of Internal Medicine, Università degli Studi di Genova, & Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Martine Piccart
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. J Breast Imaging 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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Kotteas E, Bielo LB, Valenza C, Santoro C, Koukoutzeli C, Trapani D, Curigliano G. Treatment optimization in early triple negative breast cancer. Expert Rev Anticancer Ther 2023; 23:1107-1116. [PMID: 37873652 DOI: 10.1080/14737140.2023.2268840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The treatment of early-stage triple-negative breast cancer (TNBC) has radically changed in recent years. Response to neoadjuvant treatment has provided prognostic information, and the achievement of a pathological complete response (pCR) is associated with improved prognosis. An exact treatment algorithm that embraces the trade-off of efficacy and toxicity in a risk-adapted manner has, however, not been consolidated. AREAS COVERED In this review, we focused on the current treatments used for patients with early triple negative breast cancer, aiming at framing a therapeutic approach toward risk-adapted treatment optimization. We reviewed the clinical trials and other evidence at the foundation of the current clinical practice in early TNBC and identified possible areas of clinical implementation. EXPERT OPINION In our opinion, treatment optimization will ensure improved patient-centric outcomes, with less toxicities, better long-term quality of life and risk-adapted treatment modulation. Presently, treatment modulation can be applied in some patients through de-intensification, for small TNBC, informed by novel biomarkers and based on the response to neoadjuvant treatments, especially in the case of pCR. Innovative approaches should incorporate baseline risk and cancer biology, treatment response, and post-surgery biomarkers of prognosis, to deliver risk-adapted treatments for patients with early TNBC.
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Affiliation(s)
- Elias Kotteas
- Oncology Unit, 3rd Department of Internal Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Luca Boscolo Bielo
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carmine Valenza
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Celeste Santoro
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Chrysanthi Koukoutzeli
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
| | - Dario Trapani
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Owusu-Brackett N, Oppong BA. Can targeted axillary dissection reliably advise de-escalation of completion axillary lymph node dissection? Gland Surg 2023; 12:730-732. [PMID: 37441015 PMCID: PMC10333758 DOI: 10.21037/gs-23-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/12/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Nicci Owusu-Brackett
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Bridget A Oppong
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
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22
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Lee SY, Geisler T, Motovska Z, Jeong YH. Editorial: The individualization of antiplatelet therapy in coronary artery disease: escalation or de-escalations. Front Cardiovasc Med 2023; 10:1219689. [PMID: 37346282 PMCID: PMC10280152 DOI: 10.3389/fcvm.2023.1219689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Sang Yeub Lee
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls Universtität Tübingen, Tübingen, Germany
| | - Zuzana Motovska
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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23
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Weiss KJ. Suicide by Cop and Civil Liability for Police. J Am Acad Psychiatry Law 2023; 51:204-214. [PMID: 37001890 DOI: 10.29158/jaapl.220062-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Suicide by cop (SbC) is a variant of victim-precipitated homicide. In SbC, a citizen intent on dying provokes police, often with credible threats of violence. A fatality results in ambiguity about manner of death (homicide versus suicide). Decedents' families may raise claims of civil-rights violations, asserting insufficient restraint by officers. Police officers, when questioned, may justify their actions as reasonable and necessary force. Defendant officers and municipalities are concerned about police safety and adverse economic and public-perception consequences of litigation. This article explores the history and evolution of the SbC phenomenon, examines related civil case law, and reviews the contours of police-citizen interactions in SbC cases. There is potential liability for officers whose actions must be objectively reasonable to prevail in court. Since SbC can be admitted as evidence, there may be an expanded role for forensic psychiatry in distinguishing manner of death. Expert testimony can also aid fact finders in appreciating the decisions of officers faced with ambiguous and threatening situations. The author recommends collaboration between law enforcement and mental health professionals to improve recognition and handling of difficult situations involving persons with mental illness.
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Affiliation(s)
- Kenneth J Weiss
- Dr. Weiss is Clinical Professor of Psychiatry and Core Faculty in the Forensic Psychiatry Fellowship Program at Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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24
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Duncan G, Gable B, Schabbing M. Interdisciplinary Simulation Training Reduces Restraint Use in the Emergency Department: A Pilot Study. Cureus 2023; 15:e39847. [PMID: 37397654 PMCID: PMC10314820 DOI: 10.7759/cureus.39847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Safe and effective management of agitated patients poses multiple challenges for healthcare professionals. Patients placed in restraints because of agitated behavior are at a higher risk of complications, including death. This intervention was designed to provide emergency department staff a framework for de-escalation, improve teamwork, and reduce the use of violent physical restraints. Methods Emergency medicine nurses, patient support associates, and protective services officers underwent a 90-minute educational intervention in 2017. A 30-minute lecture focusing on communication and early use of medication for agitation was followed by a simulation using standardized participants, then a structured debriefing. A standardized return-on-learning tool determined participants' reactions to and application of the educational intervention. Additionally, data was collected and reported as a ratio of number of restraints applied each month compared to total emergency department visits that month. Data were analyzed comparing the six months before the education and the subsequent six months after the education. Results A pilot group of 30 emergency department staff members completed the educational intervention. The intervention contributed to the overall decrease in restraint use in the department. Most participants (86%) felt more confident in their ability to manage agitated patients. Conclusion An interdisciplinary simulation-enhanced educational intervention successfully reduced use of restraints in the emergency department and improved staff attitudes toward de-escalation techniques for agitated patients.
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Affiliation(s)
- Gary Duncan
- Medical Education and Simulation, OhioHealth, Columbus, USA
| | - Brad Gable
- Emergency Medicine, OhioHealth, Columbus, USA
| | - Megan Schabbing
- Psychiatry and Behavioral Sciences, OhioHealth, Columbus, USA
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25
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Beck AC, Morrow M. Axillary lymph node dissection: Dead or still alive? Breast 2023; 69:469-475. [PMID: 36702672 PMCID: PMC10300611 DOI: 10.1016/j.breast.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/24/2023] Open
Abstract
Although sentinel lymph node biopsy is now the primary method of axillary staging and is therapeutic for patients with limited nodal disease, axillary lymph node dissection (ALND) is still necessary for staging in groups where sentinel lymph node biopsy has not been proven to be accurate and to maintain local control in those with a heavy axillary tumor burden. Additionally, newer approaches to systemic therapy tailored to risk level sometimes necessitate knowledge of the number of involved axillary nodes which can only be obtained with ALND. Ongoing trials will address whether there are additional circumstances where radiotherapy can replace ALND.
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Affiliation(s)
- Anna C Beck
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
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26
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El Abdallaoui OEA, Tornyos D, Lukács R, Szabó D, Komócsi A. Individualized or Uniform De-Escalation Strategies for Antiplatelet Therapy in Acute Coronary Syndrome: A Review of Clinical Trials with Platelet Function Testing and Genetic Testing-Based Protocols. Int J Mol Sci 2023; 24:ijms24109071. [PMID: 37240417 DOI: 10.3390/ijms24109071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
This comprehensive literature review assessed the effectiveness of precision medicine approaches in individualizing P2Y12 de-escalation strategies, such as platelet function testing guidance, genetic testing guidance, and uniform de-escalation, for acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Analyzing six trials with a total of 13,729 patients, the cumulative analyses demonstrated a significant reduction in major adverse cardiac events (MACE), net adverse clinical events (NACE), and major and minor bleeding events with P2Y12 de-escalation. Specifically, the analysis found a 24% reduction of MACE and a 22% reduction of adverse event risk (relative risk (RR) 0.76, 95% confidence interval (CI): 0.71-0.82, and RR: 0.78, 95% CI 0.67-0.92, respectively). Reductions in bleeding events were highest with uniform unguided de-escalation, followed by guided de-escalations, while ischemic event rates were similarly lower across all three strategies. Although the review highlights the potential of individualized P2Y12 de-escalation strategies to offer a safer alternative to the long-term potent P2Y12 inhibitor-based dual antiplatelet therapy, it also indicates that laboratory-guided precision medicine approaches may not yet offer the expected benefits, necessitating further research to optimize individualized strategies and evaluate the potential of precision medicine approaches in this context.
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Affiliation(s)
| | - Dániel Tornyos
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Réka Lukács
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Dóra Szabó
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
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Alharbi RA, Aldardeer NF, Heaphy ELG, Alabbasi AH, Albuqami AM, Hawa H. Percent fluid overload for prediction of fluid de-escalation in critically ill patients in Saudi Arabia: a prospective observational study. Acute Crit Care 2023; 38:209-216. [PMID: 37313667 DOI: 10.4266/acc.2022.01550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients. METHODS This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first. RESULTS A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during their ICU stay, while 39 (39.0%) did not. Median percent fluid accumulation on the day of deresuscitation or ICU discharge was 4.5% (interquartile range [IQR], 1.7%-9.1%) and 5.2% (IQR, 2.9%-7.7%) in patients requiring deresuscitation and those who did not, respectively. Hospital mortality occurred in 25 (40.9%) of patients with deresuscitation and six (15.3%) patients who did not require it (P=0.007). CONCLUSIONS The percent fluid accumulation on the day of fluid deresuscitation or ICU discharge was not statistically different between patients who required fluid deresuscitation and those who did not. A larger sample size is needed to confirm these findings.
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Affiliation(s)
- Reham A Alharbi
- Division of Pharmaceutical Care, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Namareq F Aldardeer
- Division of Pharmaceutical Care, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Emily L G Heaphy
- Department of Research, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | | | | | - Hassan Hawa
- Joint CCT in Acute and Intensive Care Medicine (UK), Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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28
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Aricò MO, Valletta E, Caselli D. Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children. Children (Basel) 2023; 10:740. [PMID: 37189989 PMCID: PMC10137055 DOI: 10.3390/children10040740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".
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Affiliation(s)
- Melodie O. Aricò
- U.O. Pediatria, Ospedale G.B. Morgagni—L. Pierantoni, AUSL Romagna, 47121 Forlì, Italy; (M.O.A.); (E.V.)
| | - Enrico Valletta
- U.O. Pediatria, Ospedale G.B. Morgagni—L. Pierantoni, AUSL Romagna, 47121 Forlì, Italy; (M.O.A.); (E.V.)
| | - Désirée Caselli
- U.O.C. Malattie Infettive, Ospedale Pediatrico Giovanni XXIII, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70100 Bari, Italy
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García-Anaya MJ, Segado-Guillot S, Cabrera-Rodríguez J, Toledo-Serrano MD, Medina-Carmona JA, Gómez-Millán J. DOSE AND VOLUME DE-ESCALATION OF RADIOTHERAPY IN HEAD AND NECK CANCER. Crit Rev Oncol Hematol 2023; 186:103994. [PMID: 37061074 DOI: 10.1016/j.critrevonc.2023.103994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 04/17/2023] Open
Abstract
Radiotherapy plays a key role in the treatment of head and neck cancer. However, irradiation of the head and neck region is associated with high rates of acute and chronic toxicity. Technological advances have led to better visualisation of target volumes and critical structures and improved dose conformality in the treatment volume. Despite this, acute toxicity has not been substantially reduced and late toxicity has a significant impact on patients' quality of life. The greater radiosensitivity of tumours associated with the HPV and the development of new imaging techniques have encouraged research into new deintensified strategies to reduce the side effects of radiotherapy. The aim of this paper is to review the literature on the strategies of de-escalated treatment in dose and/or volume in head and neck cancer.
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Affiliation(s)
- M J García-Anaya
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, Malaga, Spain.
| | - S Segado-Guillot
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - J Cabrera-Rodríguez
- Department of Radiation Oncology, Hospital Universitario de Badajoz. Badajoz, Spain
| | - M D Toledo-Serrano
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - J A Medina-Carmona
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - J Gómez-Millán
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, Malaga, Spain; Instituto de Investigación Biomédica de Malaga, Malaga, Spain
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30
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Bucchi L, Ravaioli A, Dal Maso L, Falcini F, Mangone L, Massarut S, Schirosi L, Crispo A, Vici P, Franceschi S. De-Implementation of Axillary Staging and Radiotherapy in Low-Risk Breast Cancer Patients Aged 70-79 Years from Six Italian Cancer Institutes. Curr Oncol 2023; 30:4177-4184. [PMID: 37185431 PMCID: PMC10137373 DOI: 10.3390/curroncol30040318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
In women aged ≥70 with low-risk breast cancer (BrC), some major international guidelines recommend against sentinel lymph node biopsy (for example, those from the Society of Surgical Oncology, U.S.) and post-lumpectomy radiotherapy (for example, those from the National Comprehensive Cancer Network, U.S.). We assessed the frequency of both procedures in six National Cancer Institutes (IRCCSs) in the North, the Centre, and the South of Italy. Data on tumour characteristics and treatment were obtained from each centre. Patients aged 70-79 years diagnosed with a pT1-pT2, clinically axillary lymph node-negative, oestrogen and/or progesterone receptor-positive, and human epidermal growth factor receptor 2-negative BrC between 2015 and 2020 were eligible for the study. Factors associated with the omission of the two procedures were evaluated using binary penalised logistic regression models. Axillary staging was omitted in 33/1000 (3.3%) women. After simultaneous adjustment for the centre of treatment and all other key variables, axillary staging was omitted more often in 2015-2016 vs. 2017-2020 (odds ratio (OR): 2.7; 95% CI: 1.0-7.5), in women aged 75-79 vs. 70-74 years (OR: 2.3; 95% CI: 1.1-4.9), and in those who had mastectomy vs. breast-conserving surgery (OR: 3.3; 95% CI: 1.2-9.0). The higher the histological grade was, the less frequent were the omissions (OR for grade 3 vs. grade 1: 0.2; 95% CI: 0.0-0.7). Post-lumpectomy radiotherapy was omitted in 56/651 (8.6%) women with no significant association with age, period, tumour stage, and tumour grade. In conclusion, the omission of axillary staging and post-lumpectomy radiotherapy in low-risk older BrC patients was rare in the Italian IRCCSs. Although women included in the study cannot be considered a nationally representative sample of BrC patients in Italy, our findings can serve as a baseline to monitor the impact of future guidelines. To do that, the recording and storage of hospital-based information should be improved.
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Affiliation(s)
- Lauro Bucchi
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, 47014 Meldola, Forlì, Italy
| | - Alessandra Ravaioli
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, 47014 Meldola, Forlì, Italy
| | - Luigino Dal Maso
- SOC Epidemiologia Oncologica, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Fabio Falcini
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, 47014 Meldola, Forlì, Italy
| | - Lucia Mangone
- Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Samuele Massarut
- SOC di Chirurgia Oncologica del Seno, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Laura Schirosi
- U.O.C. Anatomia Patologica, IRCCS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Anna Crispo
- SOC Epidemiologia e Biostatistica, Istituto Nazionale dei Tumori-IRCCS Fondazione G. Pascale, 80131 Napoli, Italy
| | - Patrizia Vici
- UOSD Sperimentazioni di FASE IV, IRCCS Istituto Nazionale Tumori Regina Elena, 00128 Roma, Italy
| | - Silvia Franceschi
- Direzione Scientifica, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
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Ju W, Zhang Y, Liu Y, Sun J, Li J, Dong M, Sun Q, Shi W, Zhao T, Zhou Z, Huang Y, Zhou X, Zhu D, Dou S, Zhang Z, He Y, Zhang C, Xia R, Zhu G, Zhong L. Can adjuvant radiotherapy be omitted for oral cavity cancer patients who received neoadjuvant therapy and surgery? A retrospective cohort study. Int J Surg 2023; 109:879-886. [PMID: 36999830 PMCID: PMC10389426 DOI: 10.1097/js9.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/09/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Surgery and postoperative adjuvant therapy comprise the standard treatment for locally advanced resectable oral squamous cell carcinoma (LAROSCC), while preoperative neoadjuvant therapy is being explored without sufficient confirmation of improved survival. De-escalation regimens after neoadjuvant therapy, such as those omitting adjuvant radiotherapy, may provide comparable or better outcomes, suggesting rigorous assessment of adjuvant therapy outcomes is needed in LAROSCC patients. The authors thus performed this retrospective study in LAROSCC patients who received neoadjuvant therapy and surgery, to compare the outcomes for overall survival (OS) and locoregional recurrence-free survival (LRFS) between the adjuvant radiotherapy (radio) and nonradiotherapy (nonradio) cohorts. MATERIALS AND METHODS Patients diagnosed with LAROSCC who received neoadjuvant therapy and surgery were enrolled and divided into radio and nonradio cohorts to determine whether adjuvant radiotherapy could be omitted after neoadjuvant therapy and surgery. RESULTS From 2008 to 2021, 192 patients were enrolled. No significant differences were found in OS or LRFS between the radio and nonradio patient cohorts. The 10-year estimated OS rates were 58.9 versus 44.1% in radio versus nonradio cohorts, while 10-year estimated LRFS rates were 55.4 versus 48.2%, respectively. For clinical stage III patients, 10-year OS rates were 62.3 versus 62.6% (radio vs. nonradio), and estimated 10-year LRFS rates were 56.5 versus 60.7% (radio vs. nonradio). Multivariate Cox regression modeling of postoperative variables showed pathologic response of primary tumor and pathologic regional lymph nodes staging were associated with survival, while the adjuvant radiotherapy exposure was not included in the model due to nonsignificance. CONCLUSION These findings support further prospective evaluation of adjuvant radiotherapy omission, and suggest that de-escalation trials are warranted for LAROSCC surgery patients who received neoadjuvant therapy.
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Affiliation(s)
- Wutong Ju
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Yiyi Zhang
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Ying Liu
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | | | | | | | | | - Wentao Shi
- Biostatistics Office of Clinical Research Unit, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University
| | - Tongchao Zhao
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Zhihang Zhou
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Yingying Huang
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Xinyu Zhou
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Dongwang Zhu
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Shengjin Dou
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Zhiyuan Zhang
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Yue He
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Chenping Zhang
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | | | - Guopei Zhu
- Departments of Oral and Maxillofacial-Head and Neck Oncology
| | - Laiping Zhong
- Departments of Oral and Maxillofacial-Head and Neck Oncology
- National Center for Stomatology
- National Clinical Research Center for Oral Diseases
- Shanghai Key Laboratory of Stomatology
- Shanghai Research Institute of Stomatology, Shanghai, People’s Republic of China
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Boersma LJ, Mjaaland I, van Duijnhoven F. Regional radiotherapy after primary systemic treatment for cN+ breast cancer patients. Breast 2023; 68:181-188. [PMID: 36805769 PMCID: PMC9975253 DOI: 10.1016/j.breast.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
Pathologic complete response (pCR) after Primary Systemic Treatment (PST) for breast cancer is associated with excellent long-term outcomes. With increasing use of PST, the indication for regional nodal irradiation (RNI) has been challenged. The aim of this paper is to review the literature on de-escalation of RNI in patients treated with PST. We found no level 1 evidence on de-escalation of RNI after PST, but several randomized trials are ongoing. Consequently, current de-escalation strategies are based on cohort studies. These studies showed that in patients with low nodal tumour burden (LNTB) (≤3 suspicious nodes at imaging) prior to PST, and ypN0 based on Axillary Lymph Node Dissection (ALND), omission of RNI resulted in very low regional recurrences (RR) without compromising survival. In patients with LNTB and ypN0 based on Sentinel Lymph Node Biopsy (SLNB), omission of axillary treatment also resulted in low RR; the majority of these patients received local radiotherapy. Similarly, in patients with ypN1 (ALND) disease, omission of RNI resulted in low 5-year RR rates. Low RR-rates were also found in the few studies replacing ALND by RNI, in patients with ypN1 (SLNB) disease. In patients with high nodal tumour burden prior to PST and ypN0 (SLNB), replacing ALND by RNI also resulted in low RR. Due to the limited number of patients, these data should be interpreted with caution. We conclude that although level 1 evidence is lacking, de-escalation of RNI after PST can be considered in selected cases.
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Affiliation(s)
- Liesbeth J Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Ingvil Mjaaland
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway.
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Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast 2023; 69:249-257. [PMID: 36898258 PMCID: PMC10017412 DOI: 10.1016/j.breast.2023.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Augsburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Center, Die Filderklinik, Filderstadt, Germany.
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Ouattara D, Mathelin C, Özmen T, Lodi M. Molecular Signatures in Ductal Carcinoma In Situ (DCIS): A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12052036. [PMID: 36902822 PMCID: PMC10004217 DOI: 10.3390/jcm12052036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
CONTEXT Adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) is debated as benefits are inconstant. Molecular signatures for DCIS have been developed to stratify the risk of local recurrence (LR) and therefore guide the decision of RT. OBJECTIVE To evaluate, in women with DCIS treated by BCS, the impact of adjuvant RT on LR according to the molecular signature risk stratification. METHODOLOGY We conducted a systematic review and meta-analysis of five articles including women with DCIS treated by BCS and with a molecular assay performed to stratify the risk, comparing the effect of BCS and RT versus BCS alone on LR including ipsilateral invasive (InvBE) and total breast events (TotBE). RESULTS The meta-analysis included 3478 women and evaluated two molecular signatures: Oncotype Dx DCIS (prognostic of LR), and DCISionRT (prognostic of LR and predictive of RT benefit). For DCISionRT, in the high-risk group, the pooled hazard ratio of BCS + RT versus BCS was 0.39 (95%CI 0.20-0.77) for InvBE and 0.34 (95%CI 0.22-0.52) for TotBE. In the low-risk group, the pooled hazard ratio of BCS + RT versus BCS was significant for TotBE at 0.62 (95%CI 0.39-0.99); however, it was not significant for InvBE (HR = 0.58 (95%CI 0.25-1.32)), Discussion: Molecular signatures are able to discriminate high- and low-risk women, high-risk ones having a significant benefit of RT in the reduction of invasive and in situ local recurrences, while in low-risk ones RT did not have a benefit for preventing invasive breast recurrence. The risk prediction of molecular signatures is independent of other risk stratification tools developed in DCIS, and have a tendency toward RT de-escalation. Further studies are needed to assess the impact on mortality.
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Affiliation(s)
- Drissa Ouattara
- Surgery Department, Point G University Hospitals, Bamako P.O. Box 251, Mali
| | - Carole Mathelin
- Strasbourg University Hospital, 1 Avenue Molière, 67200 Strasbourg, France
- Surgical Oncology Department, ICANS Institute of Oncology Strasbourg Europe, 17 Avenue Albert Calmette, CEDEX, 67200 Strasbourg, France
- IGBMC Institute of Genetics, Molecular and Cellular Biology, CNRS, UMR7104 INSERM U964, Strasbourg University, 1 Rue Laurent Fries, 67400 Illkirch-Graffenstaden, France
| | - Tolga Özmen
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Massimo Lodi
- Strasbourg University Hospital, 1 Avenue Molière, 67200 Strasbourg, France
- Surgical Oncology Department, ICANS Institute of Oncology Strasbourg Europe, 17 Avenue Albert Calmette, CEDEX, 67200 Strasbourg, France
- IGBMC Institute of Genetics, Molecular and Cellular Biology, CNRS, UMR7104 INSERM U964, Strasbourg University, 1 Rue Laurent Fries, 67400 Illkirch-Graffenstaden, France
- Correspondence:
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Aldardeer NF, Shukairi ANAL, Nasser ME, Al Musawa M, Kalkatawi BS, Alsahli RM, Ramdan AME, Qushmaq I, Aldhaeefi M. Continuation Versus De-escalation of Broad-Spectrum Antibiotic Therapy in Critically Ill COVID-19 Patients. Dr. Sulaiman Al Habib Med J 2023. [PMCID: PMC9972303 DOI: 10.1007/s44229-023-00027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Background Antibiotic de-escalation (ADE) is a stewardship initiative that aims to reduce exposure to antimicrobials, thus limiting their unwanted effect, including antimicrobial resistance. Our study aims to describe the impact of ADE compared with the continuation of therapy on the outcome of critically ill coronavirus disease 2019 (COVID-19) patients. Material and Methods A single-center retrospective study included critically ill COVID-19 adult patients admitted between January 1, 2019 and August 31, 2021, and started on broad-spectrum antibiotics. The primary outcome was intensive care unit (ICU) mortality. In addition, other clinical outcomes were evaluated, including ICU readmissions, length of stay, and superinfection. Results The study included 73 patients with a mean age of 61.0 ± 19.4, and ADE was performed in 10 (13.6%) of these. In the ADE group, 8/10 (80%) cultures were positive. ICU mortality was not statistically different between ADE and continuation of therapy groups (60 vs. 41.3%, respectively, P = 0.317). Superinfection occurred in 4 (5.4%) patients. Hospital mortality, length of stay, and ICU readmission rates did not differ significantly between groups. Conclusion De-escalation of broad-spectrum antibiotics in critically ill covid-19 patients was not associated with higher mortality. A larger cohort is needed to confirm these findings. Supplementary Information The online version contains supplementary material available at 10.1007/s44229-023-00027-0.
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Affiliation(s)
| | - Abeer Nizar A. L. Shukairi
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia ,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mohannad E. Nasser
- King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohammad Al Musawa
- Medication Safety/Clinical Support Pharmacy, King Faisal Specialist Hospital and Research Centre (Gen. Org.), Jeddah, Saudi Arabia
| | | | | | | | - Ismael Qushmaq
- Section of Critical Care Medicine, Department of Medicine, King Faisal Specialist Hospital and Research Center (Gen. Org.), Jeddah, Saudi Arabia
| | - Mohammed Aldhaeefi
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
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Riaz N, Jeen T, Whelan TJ, Nielsen TO. Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer. Cancers (Basel) 2023; 15. [PMID: 36831598 DOI: 10.3390/cancers15041260] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.
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Chitsike L, Bertucci A, Vazquez M, Lee S, Unternaehrer JJ, Duerksen-Hughes PJ. GA-OH enhances the cytotoxicity of photon and proton radiation in HPV + HNSCC cells. Front Oncol 2023; 13:1070485. [PMID: 36845698 PMCID: PMC9950506 DOI: 10.3389/fonc.2023.1070485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
Introduction Treatment-related toxicity following either chemo- or radiotherapy can create significant clinical challenges for HNSCC cancer patients, particularly those with HPV-associated oropharyngeal squamous cell carcinoma. Identifying and characterizing targeted therapy agents that enhance the efficacy of radiation is a reasonable approach for developing de-escalated radiation regimens that result in less radiation-induced sequelae. We evaluated the ability of our recently discovered, novel HPV E6 inhibitor (GA-OH) to radio-sensitize HPV+ and HPV- HNSCC cell lines to photon and proton radiation. Methods Radiosensitivity to either photon or proton beams was assessed using various assays such as colony formation assay, DNA damage markers, cell cycle and apoptosis, western blotting, and primary cells. Calculations for radiosensitivity indices and relative biological effectiveness (RBE) were based on the linear quadratic model. Results Our results showed that radiation derived from both X-ray photons and protons is effective in inhibiting colony formation in HNSCC cells, and that GA-OH potentiated radiosensitivity of the cells. This effect was stronger in HPV+ cells as compared to their HPV- counterparts. We also found that GA-OH was more effective than cetuximab but less effective than cisplatin (CDDP) in enhancing radiosensitivity of HSNCC cells. Further tests indicated that the effects of GA-OH on the response to radiation may be mediated through cell cycle arrest, particularly in HPV+ cell lines. Importantly, the results also showed that GA-OH increases the apoptotic induction of radiation as measured by several apoptotic markers, even though radiation alone had little effect on apoptosis. Conclusion The enhanced combinatorial cytotoxicity found in this study indicates the strong potential of E6 inhibition as a strategy to sensitize cells to radiation. Future research is warranted to further characterize the interaction of GA-OH derivatives and other E6-specific inhibitors with radiation, as well as its potential to improve the safety and effectiveness of radiation treatment for patients with oropharyngeal cancer.
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Affiliation(s)
- Lennox Chitsike
- Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Antonella Bertucci
- Department of Radiation Medicine, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Marcelo Vazquez
- Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, United States,Department of Radiation Medicine, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Steve Lee
- Department of Otolaryngology & Head/Neck Surgery, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Juli J. Unternaehrer
- Division of Biochemistry, Department of Basic Sciences, Loma Linda University, Loma Linda, CA, United States
| | - Penelope J. Duerksen-Hughes
- Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, United States,*Correspondence: Penelope J. Duerksen-Hughes,
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Doll C, Mrosk F, Freund L, Neumann F, Kreutzer K, Voss J, Raguse JD, Beck M, Böhmer D, Rubarth K, Heiland M, Koerdt S. Management of the Contralateral Neck in Unilateral Node-Positive Oral Squamous Cell Carcinoma. Cancers (Basel) 2023; 15. [PMID: 36831429 DOI: 10.3390/cancers15041088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION In lateralized oral squamous cell carcinoma (OSCC) with ipsilateral cervical lymph node metastasis (CLNM), the surgical management of the unsuspicious contralateral neck remains a matter of debate. The aim of this study was to analyze this cohort and to compare the outcomes of patients with and without contralateral elective neck dissection (END). MATERIAL AND METHODS A retrospective analysis of patients with lateralized OSCC, ipsilateral CLNM (pN+) and contralateral cN0-stage was performed. Patients were divided into two groups according to the surgical management of the contralateral neck: I: END; and II: no END performed. Adjuvant radiotherapy was applied bilaterally in both groups according to individual risk. RESULTS A total of 65 patients (group I: 16 (24.6%); group II: 49 (75.4%)) with a median follow-up of 28 months were included. Initially, there was no case of contralateral CLNM after surgery. During follow-up, 6 (9.2%) patients presented with recurrent CLNM. In 5 of these cases (7.7%), the contralateral neck (group I: 3/16 (18.8%); group II: 2/49 (4.1%)) was affected. Increased ipsilateral lymph node ratio was associated with contralateral CLNM (p = 0.07). END of the contralateral side showed no significant benefit regarding OS (p = 0.59) and RFS (p = 0.19). CONCLUSIONS Overall, the risk for occult contralateral CLNM in patients with lateralized OSCC ipsilateral CLNM is low. Our data suggest that END should not be performed routinely in this cohort. Risk-adapted radiotherapy of the contralateral neck alone seems to be sufficient from the oncological point of view.
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Moehring RW, Yarrington ME, Warren BG, Lokhnygina Y, Atkinson E, Bankston A, Collucio J, David MZ, Davis AE, Davis J, Dionne B, Dyer AP, Jones TM, Klompas M, Kubiak DW, Marsalis J, Omorogbe J, Orajaka P, Parish A, Parker T, Pearson JC, Pearson T, Sarubbi C, Shaw C, Spivey J, Wolf R, Wrenn RH, Dodds Ashley ES, Anderson DJ. Evaluation of an Opt-Out Protocol for Antibiotic De-Escalation in Patients With Suspected Sepsis: A Multicenter, Randomized, Controlled Trial. Clin Infect Dis 2023; 76:433-442. [PMID: 36167851 DOI: 10.1093/cid/ciac787] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/09/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. This randomized, controlled trial evaluated an opt-out protocol to decrease unnecessary antibiotics in patients with suspected sepsis. METHODS We evaluated non-intensive care adults on broad-spectrum antibiotics despite negative blood cultures at 10 US hospitals from September 2018 through May 2020. A 23-item safety check excluded patients with ongoing signs of systemic infection, concerning or inadequate microbiologic data, or high-risk conditions. Eligible patients were randomized to the opt-out protocol vs usual care. Primary outcome was post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted to encourage antibiotic discontinuation using opt-out language. If continued, clinicians discussed the rationale for continuing antibiotics and de-escalation plans. To evaluate those with zero post-enrollment DOT, hurdle models provided 2 measures: odds ratio of antibiotic continuation and ratio of mean DOT among those who continued antibiotics. RESULTS Among 9606 patients screened, 767 (8%) were enrolled. Intervention patients had 32% lower odds of antibiotic continuation (79% vs 84%; odds ratio, 0.68; 95% confidence interval [CI], .47-.98). DOT among those who continued antibiotics were similar (ratio of means, 1.06; 95% CI, .88-1.26). Fewer intervention patients were exposed to extended-spectrum antibiotics (36% vs 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%). Thirty-day safety events were similar. CONCLUSIONS An antibiotic opt-out protocol that targeted patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm. CLINICAL TRIALS REGISTRATION NCT03517007.
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Affiliation(s)
- Rebekah W Moehring
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael E Yarrington
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Bobby G Warren
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Erica Atkinson
- Department of Pharmacy, Southeastern Regional Medical Center, Lumberton, North Carolina, USA
| | - Allison Bankston
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | - Julia Collucio
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Michael Z David
- Department of Medicine, Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelina E Davis
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Janice Davis
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Brandon Dionne
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pharmacy and Health Systems Sciences, Northeastern University School of Pharmacy and Pharmaceutical Sciences, Boston, Massachusetts, USA
| | - April P Dyer
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Travis M Jones
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael Klompas
- Department of Medicine, Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John Marsalis
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | | | - Patricia Orajaka
- Department of Pharmacy, Iredell Health, Statesville, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Todd Parker
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tonya Pearson
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Christina Sarubbi
- Department of Pharmacy, UNC REX Healthcare, Raleigh, North Carolina, USA
| | - Christian Shaw
- Department of Pharmacy, Wilson Medical Center, Wilson, North Carolina, USA
| | - Justin Spivey
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert Wolf
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebekah H Wrenn
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth S Dodds Ashley
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Chua MLK, Lua JYH, Ng WT, Lee AWM. Management of the neck in nasopharyngeal carcinoma-time for a radical change? Chin Clin Oncol 2023; 12:8. [PMID: 36809908 DOI: 10.21037/cco-22-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/06/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Melvin L K Chua
- Division of Radiation Oncology and Division of Medical Sciences, Department of Head and Neck and Thoracic Cancers, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | | | - Wai-Tong Ng
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Anne W M Lee
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Shamash J, Ng K. Balancing efficacy with long-term side-effects: can we safely de-escalate therapy for germ cell tumors? Expert Rev Anticancer Ther 2023; 23:127-134. [PMID: 36648077 DOI: 10.1080/14737140.2023.2162042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The success in the management of germ cell tumors has encouraged researchers to pay more attention on long-term side effects and other survivorship issues. The de-escalation of treatment is intended to reduce side effects but must be balanced against any compromise of efficacy. Cisplatin-based therapy is the cornerstone of treatment for germ cell tumors. However, they can result in acute and long-term side effects, including ototoxicity, neurotoxicity, nephrotoxicity, and increased risk of second malignancies. AREAS COVERED This review discusses approaches of de-escalation including biomarker-directed treatment using microRNAs, surveillance for immature teratoma, the use of carboplatin monotherapy for seminoma, and the option of non-cisplatin-based approaches in relapsed germ cell tumors. EXPERT OPINION While the results with the current standard options in terms of cancer control are very good, the price being paid in terms of long-term side effects is considerable.
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Affiliation(s)
| | - Kenrick Ng
- Medical Oncology, Barts Health NHS Trust, London, UK
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Haseeb A, Saleem Z, Altaf U, Batool N, Godman B, Ahsan U, Ashiq M, Razzaq M, Hanif R, E-Huma Z, Amir A, Hossain MA, Raafat M, Radwan RM, Iqbal MS, Kamran SH. Impact of Positive Culture Reports of E. coli or MSSA on De-Escalation of Antibiotic Use in a Teaching Hospital in Pakistan and the Implications. Infect Drug Resist 2023; 16:77-86. [PMID: 36636371 PMCID: PMC9831081 DOI: 10.2147/idr.s391295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
Background Antibiotic de-escalation is a key element of antimicrobial stewardship programs that restrict the spread and emergence of resistance. This study was performed to evaluate the impact of positive culture sensitivity reports of E. coli or Methicillin sensitive Staphylococcus aureus (MSSA) on de-escalation of antibiotic therapy. Methods This prospective observational study was performed on 256 infected patients. The samples were obtained principally from the pus of infected sites for the identification of pathogens and culture-sensitivity testing. The data were collected from patient medical files, which included their demographic data, sample type, causative microbe and antimicrobial treatment as empiric or definitive treatment based on cultures. Data were analyzed using SPSS. Results Of 256 isolated microbes, 138 (53.9%) were MSSA and 118 were E. coli (46.1%). MSSA showed 100% sensitivity to cefoxitin, oxacillin, vancomycin, fosfomycin, colistin and more than 90% to linezolid (95.3%), tigecycline (93.1%), chloramphenicol (92.2%) and amikacin (90.2%). E. coli showed 100% sensitivity to only fosfomycin and more than 90% to colistin (96.7%), polymyxin-B (95.1%) and tigecycline (92.9%). The high use of cefoperazone+sulbactam (151), amikacin (149), ceftriaxone (33), metronidazole (30) and piperacillin + tazobactam (22) was seen with empiric prescribing. Following susceptibility testing, the most common antibiotics prescribed for E. coli were meropenem IV (34), amikacin (34), ciprofloxacin (29) and cefoperazone+sulbactam (25). For MSSA cases, linezolid (48), clindamycin (30), cefoperazone+ sulbactam IV (16) and amikacin (15) was used commonly. Overall, there was 23% reduction in antibiotic use in case of E. coli and 43% reduction in MSSA cases. Conclusion Culture sensitivity reports helped in the de-escalation of antimicrobial therapy, reducing the prescribing of especially broad-spectrum antibiotics. Consequently, it is recommended that local hospital guidelines be developed based on local antimicrobial susceptibility patterns while preventing the unnecessary use of broad-spectrum antibiotics for empiric treatment.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan,Correspondence: Zikria Saleem, Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan, Email
| | - Ummara Altaf
- Department of Pharmacy, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Narjis Batool
- Australian Institute of Health Innovation, Center of Health Systems and Safety Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK,School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa,Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Umar Ahsan
- Department of Infection Prevention and Control, Al Noor Specialist Hospital, Ministry of health, Makkah, Kingdom of Saudi Arabia
| | - Mehreen Ashiq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Mutiba Razzaq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Rabia Hanif
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Zill E-Huma
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mohammad Akbar Hossain
- Department of Pharmacology and Toxicology, Faculty of Medicine in Al-Qunfudah, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Mohamed Raafat
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Al Noor Specialist Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
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Haddon AM, Gross KR, Mozes CJ. Impact of Clinical Pharmacist Practitioner Management of Chronic Obstructive Pulmonary Disease in the Ambulatory Care Setting. J Pharm Pract 2023:8971900221150286. [PMID: 36599814 DOI: 10.1177/08971900221150286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objectives: To evaluate the impact of clinical pharmacist practitioner (CPP) management on potentially inappropriate use of inhaled corticosteroids (ICS) in the ambulatory care setting. Design: Multicenter, prospective quality assurance/improvement (QA/QI) project. Setting: Erie Veterans Affairs Medical Center (VAMC) and surrounding Ashtabula, Crawford, and Venango County Community-Based Outpatient Clinics (CBOCs). Participants: Thirty-five participants with chronic obstructive pulmonary disease (COPD) who met inclusion criteria were included in the project. Interventions: Participants were contacted to schedule an initial sixty-minute telephone visit with a CPP. Exacerbation history, rescue inhaler use, and symptom burden were assessed using the COPD Assessment Test (CAT) and Modified Medical Research Counsel Breathlessness Scale (mMRC) scales. Medication regimens were optimized based on guideline recommendations with an emphasis on appropriate use of ICS. Participants were scheduled for follow-up telephone visits with the CPP every 4 weeks. Main Outcome Measures: The primary project outcome was potentially inappropriate use of ICS without a long-acting muscarinic antagonist (LAMA)/long-acting beta agonist (LABA). Secondary project outcomes included ICS de-escalation, vaccinations, and smoking cessation. Results: The primary outcome of reducing use of ICS without a LAMA/LABA was achieved in thirty-one (88.6%) participants. ICS de-escalation was achieved in twenty-three (65.7%) participants. Rates of recommended vaccinations and smoking cessation with nicotine replacement therapy increased as a result of pharmacist intervention. Conclusion: Pharmacist management of COPD in the ambulatory care setting was associated with a decrease in potentially inappropriate use of ICS and an increase in preventative care measures.
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Affiliation(s)
- Alexa M Haddon
- Pharmacy Department, 20093Erie VA Medical Center, Erie, PA, USA
| | - Kylee R Gross
- Pharmacy Department, 20093Erie VA Medical Center, Erie, PA, USA
| | - Cassandra J Mozes
- Pharmacy Department, 20081Chillicothe VA Medical Center, Chillicothe, OH, USA
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van Dijk D, Groen AH, van Dijk BAC, van Veen TL, Sluiter WJ, Links TP, Plukker JTHM. The outcome of treatment in differentiated thyroid cancer according to recommendations in current Dutch and American guidelines. Clin Endocrinol (Oxf) 2023; 98:123-130. [PMID: 35781313 PMCID: PMC10087791 DOI: 10.1111/cen.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/06/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Assessment of treatment outcome in current de-escalation for differentiated thyroid cancer (DTC) according to the 2015 Dutch thyroid cancer guidelines (NL-15) and American Thyroid Association guidelines (ATA-15). DESIGN Retrospectively, the recommendations of the NL-15 and ATA-15 guidelines were evaluated to estimate potentially adequate, under- and overtreatment of DTC in patients treated in the University Medical Center Groningen between 2007 and 2017. PATIENTS A total of 240 patients with a cT1-T3aN0-1aM0 DTC fulfilled the inclusion criteria. MEASUREMENTS After actual treatment was given, patients were again categorized according to both guidelines into low, intermediate, or high-risk based on tumour status. Next, they were categorized into a congruent low-risk (n = 60), congruent high-risk (n = 73), or incongruent risk group (n = 107). Follow-up data were used to estimate the proportion of potentially adequate, under-, and overtreatment according to both guidelines. RESULTS Comparing treatment recommended by NL-15 and ATA-15 showed significantly more over- and adequate treatment when following NL-15 recommendations, and more undertreatment following ATA-15 (all: p < .001). Subanalysis of the congruent low-risk group showed overtreatment in 64% when following NL-15 guidelines (p < .001). No treatment differences were found in the congruent high-risk group. Undertreatment was most often seen in the incongruent risk group when following ATA-15 (p < .001). CONCLUSIONS Low-risk patients were treated too aggressively when following NL-15 recommendations, where the less aggressive ATA-15 approach seemed more adequate. Treatment of intermediate risk DTC patients varies greatly, with a relative higher rate of undertreatment according to the recommendations of the ATA-15, advocating further refining of the risk classification in this patient group.
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Affiliation(s)
- Deborah van Dijk
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andries H Groen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Boukje A C van Dijk
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim L van Veen
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wim J Sluiter
- Department of Internal Medicine, Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thera P Links
- Department of Internal Medicine, Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - John T H M Plukker
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Gianni C, Palleschi M, Merloni F, Bleve S, Casadei C, Sirico M, Di Menna G, Sarti S, Cecconetto L, Mariotti M, De Giorgi U. Potential Impact of Preoperative Circulating Biomarkers on Individual Escalating/de-Escalating Strategies in Early Breast Cancer. Cancers (Basel) 2022; 15:96. [PMID: 36612091 PMCID: PMC9817806 DOI: 10.3390/cancers15010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
The research on non-invasive circulating biomarkers to guide clinical decision is in wide expansion, including the earliest disease settings. Several new intensification/de-intensification strategies are approaching clinical practice, personalizing the treatment for each patient. Moreover, liquid biopsy is revealing its potential with multiple techniques and studies available on circulating biomarkers in the preoperative phase. Inflammatory circulating cells, circulating tumor cells (CTCs), cell-free DNA (cfDNA), circulating tumor DNA (ctDNA), and other biological biomarkers are improving the armamentarium for treatment selection. Defining the escalation and de-escalation of treatments is a mainstay of personalized medicine in early breast cancer. In this review, we delineate the studies investigating the possible application of these non-invasive tools to give a more enlightened approach to escalating/de-escalating strategies in early breast cancer.
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Affiliation(s)
- Caterina Gianni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, 47014 Meldola, Italy
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Maeda M, Nakata M, Naito Y, Yamaguchi K, Yamada K, Kinase R, Takuma T, On R, Tokimatsu I. Days of Antibiotic Spectrum Coverage Trends and Assessment in Patients with Bloodstream Infections: A Japanese University Hospital Pilot Study. Antibiotics (Basel) 2022; 11. [PMID: 36551402 DOI: 10.3390/antibiotics11121745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/11/2022] Open
Abstract
The antibiotic spectrum is not reflected in conventional antimicrobial metrics. Days of antibiotic spectrum coverage (DASC) is a novel quantitative metric for antimicrobial consumption developed with consideration of the antibiotic spectrum. However, there were no data regarding disease and pathogen-specific DASC. Thus, this study aimed to evaluate the DASC trend in patients with bloodstream infections (BSIs). DASC and days of therapy (DOT) of in-patients with positive blood culture results during a 2-year interval were evaluated. Data were aggregated to calculate the DASC, DOT, and DASC/DOT per patient stratified by pathogens. During the 2-year study period, 1443 positive blood culture cases were identified, including 265 suspected cases of contamination. The overall DASC, DASC/patient, DOT, DOT/patient, and DASC/DOT metrics were 226,626; 157.1; 28,778; 19.9; and 7.9, respectively. A strong correlation was observed between DASC and DOT, as well as DASC/patient and DOT/patient. Conversely, DASC/DOT had no correlation with other metrics. The combination of DASC and DOT would be a useful benchmark for the overuse and misuse evaluation of antimicrobial therapy in BSIs. Notably, DASC/DOT would be a robust metric to evaluate the antibiotic spectrum that was selected for patients with BSIs.
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Muthspiel M, Kaufmann CC, Burger AL, Panzer B, Verheugt FWA, Huber K. Short dual antiplatelet therapy and dual antiplatelet therapy de-escalation after primary percutaneous intervention: For whom and how. Front Cardiovasc Med 2022; 9:1008194. [PMID: 36440022 PMCID: PMC9684463 DOI: 10.3389/fcvm.2022.1008194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/25/2022] [Indexed: 03/14/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) for 6-12 months, followed by lifelong aspirin monotherapy is considered an effective standard therapy for the prevention of thrombo-ischemic events in patients with acute and chronic coronary syndrome (ACS, CCS) undergoing percutaneous coronary intervention (PCI) or after a primarily conservative treatment decision. In ACS patients, the stronger P2Y12-inhibitors ticagrelor or prasugrel are recommended in combination with aspirin unless the individual bleeding risk is high and shortening of DAPT is warranted or clopidogrel is preferred. However, also in patients at low individual bleeding risk, DAPT is associated with a higher risk of bleeding. In recent years, new antithrombotic treatment strategies, such as shortening DAPT followed by early P2Y12-inhibitor monotherapy and de-escalating DAPT from potent P2Y12-inhibitors to clopidogrel by maintaining DAPT duration time, have been investigated in clinical trials and shown to reduce bleeding complications in cardiovascular high-risk patients without negative effects on ischemic events. In this review, we summarize the current knowledge and discuss its implication on future antithrombotic strategies in terms of a personalized medicine.
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Affiliation(s)
- Marie Muthspiel
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Christoph C. Kaufmann
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Achim Leo Burger
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Benjamin Panzer
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | | | - Kurt Huber
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
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Svajdova M, Dubinsky P, Kazda T, Jeremic B. Human Papillomavirus-Related Non-Metastatic Oropharyngeal Carcinoma: Current Local Treatment Options and Future Perspectives. Cancers (Basel) 2022; 14:5385. [PMID: 36358801 PMCID: PMC9658535 DOI: 10.3390/cancers14215385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 08/26/2023] Open
Abstract
Over the last two decades, human papillomavirus (HPV) has caused a new pandemic of cancer in many urban areas across the world. The new entity, HPV-associated oropharyngeal squamous cell carcinoma (OPSCC), has been at the center of scientific attention ever since, not only due to its distinct biological behavior, but also because of its significantly better prognosis than observed in its HPV-negative counterpart. The very good treatment outcomes of the disease after primary therapy (minimally-invasive surgery, radiation therapy with or without chemotherapy) resulted in the creation of a separate staging system, reflecting this excellent prognosis. A substantial proportion of newly diagnosed HPV-driven OPSCC is diagnosed in stage I or II, where long-term survival is observed worldwide. Deintensification of the primary therapeutic methods, aiming at a reduction of long-term toxicity in survivors, has emerged, and the quality of life of the patient after treatment has become a key-point in many clinical trials. Current treatment recommendations for the treatment of HPV-driven OPSCC do not differ significantly from HPV-negative OPSCC; however, the results of randomized trials are eagerly awaited and deemed necessary, in order to include deintensification into standard clinical practice.
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Affiliation(s)
- Michaela Svajdova
- Department of Radiation and Clinical Oncology, General Hospital Rimavska Sobota, 979 01 Rimavska Sobota, Slovakia
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Pavol Dubinsky
- Department of Radiation Oncology, East Slovakia Oncology Institute, 040 01 Kosice, Slovakia
- Faculty of Health, Catholic University Ruzomberok, 034 01 Ruzomberok, Slovakia
| | - Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 602 00 Brno, Czech Republic
| | - Branislav Jeremic
- School of Medicine, University of Kragujevac, 340 00 Kragujevac, Serbia
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Felice Gragnano, Antonio Capolongo, Fabrizia Terracciano, Giuseppe Gargiulo, Vincenzo De Sio, Arturo Cesaro, Elisabetta Moscarella, Giuseppe Patti, Italo Porto, Giovanni Esposito, Dominick J. Angiolillo, Paolo Calabrò. Escalation and De-Escalation of Antiplatelet Therapy after Acute Coronary Syndrome or PCI: Available Evidence and Implications for Practice. J Clin Med 2022; 11:6246. [PMID: 36362474 DOI: 10.3390/jcm11216246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard for the antithrombotic management of patients with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Implementation of intensified or prolonged DAPT regimens has proven to lower the risk of ischemic events but at the expense of increased bleeding. Importantly, bleeding is a predictor of poor prognosis. Risk stratification and selection of tailored antiplatelet strategies to maximize the net clinical benefit in individual patients with ACS or undergoing PCI is therefore potentially beneficial. Recently, novel approaches including DAPT de-escalation or escalation have been proposed as possible alternatives to standard DAPT. These strategies, which are generally based on patient's risk profile, genetics, and/or platelet function have been proposed to offer more tailored treatments in patients with ACS or PCI, with the ultimate goal of providing adequate ischemic protection while mitigating the risk of bleeding. This review summarizes the available evidence on DAPT de-escalation or escalation (both guided and unguided) and discusses the practical implications of these strategies in the contemporary management of patients with ACS and/or undergoing PCI.
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50
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Da Silva A, Fléchon A, Coquan E, Planchamp F, Culine S, Murez T, Méjean A, Pasquier D, Chevreau C, Fizazi K, Thiery-Vuilemin A, Joly F. How to improve adherence of guidelines for localized testicular cancer surveillance: A Delphi consensus study. Front Oncol 2022; 12:1036190. [PMID: 36324582 PMCID: PMC9619048 DOI: 10.3389/fonc.2022.1036190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
Stage-I testicular germ-cell tumor (TGCT) has excellent cure rates. Surveillance is fully included in patient's management, particularly during the first years of follow-up. Surveillance guidelines differ between the academic societies, mainly concerning imaging frequency and long-term follow-up. We evaluated surveillance practice and schedules followed by French specialists and set up a DELPHI method to obtain a consensual surveillance program with an optimal schedule for patients with localized TGCT. First, an online survey on surveillance practice of stage-I TGCT based on clinical-cases was conducted among urologists, radiation-oncologists and medical-oncologists. These results were compared to ESMO/EAU and AFU guidelines. Then a panel of experts assessed surveillance proposals following a Delphi-CM. Statements were drafted after analysis of the previous survey and systematic literature review, with 2 successive rounds to reach a consensus. The study was conducted between July 2018 and May 2019. Concerning the first step: 61 participated to the survey (69% medical-oncologists, 15% urologists, 16% radiation-oncologists). About 65% of practitioners followed clinico-biological guidelines concerning 1 to 5 years of follow-up, but only 25% stopped surveillance after the 5th-year. No physician followed the EAU/ESMO guidelines of de-escalation chest imaging. Concerning the second step: 32 experts (78% medical-oncologists, 16% urologists, 6% radiation-oncologists) participated to the Delphi-CM. Thanks to Delphi-CM, a consensus was reached for 26 of the 38 statements. Experts agreed on clinico-biological surveillance modalities and end of surveillance after the 5th-year of follow-up. For seminoma, abdominal ultrasound was proposed as an option to the abdominopelvic (AP) scan for the 4th-year of follow-up. No consensus was reached regarding de-escalation of chest imaging. To conclude, the survey proved that French TGCT-specialists do not follow current guidelines. With Delphi-CM, a consensus was obtained for frequency of clinico-biological surveillance, discontinuation of surveillance after the 5th-year, stop of AP scan on the 4th-year of follow-up for seminoma. Questions remains concerning type and frequency of chest imaging.
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Affiliation(s)
| | - Aude Fléchon
- Centre Léon Bérard, Department of Medical Oncology, Lyon, France
| | - Elodie Coquan
- Centre François-Baclesse, Department of Medical Oncology, Caen, France
- Centre François-Baclesse, Clinical Research Unit, Caen, France
| | | | - Stéphane Culine
- Hôpital Saint-Louis, Department of Medical Oncology, Paris, France
| | - Thibaut Murez
- Hôpital Lapeyronie, Department of Urology, Montpellier, France
| | - Arnaud Méjean
- Georges Pompidou European Hospital, Assistance Publique Hôpitaux de Paris, Department of Urology, Paris, France
| | - David Pasquier
- Centre Oscar Lambret, Department of Radiation Oncology, Lille, France
| | | | - Karim Fizazi
- Gustave Roussy, University of Paris Sud, Department of Medical Oncology, Villejuif, France
| | | | - Florence Joly
- Centre François-Baclesse, Department of Medical Oncology, Caen, France
- Centre François-Baclesse, Clinical Research Unit, Caen, France
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