The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial

BACKGROUND

Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice.

METHODS

This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive.

DISCUSSION

TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.

A phase I/II study of bexarotene with carboplatin and weekly paclitaxel for the treatment of patients with advanced non-small cell lung cancer

BACKGROUND

Rexinoids demonstrate anti-proliferative differentiation-inducing activity in multiple cancer types, including NSCLC. Prior studies have shown promising results when combining rexinoids with chemotherapy. This phase I/II study evaluates the tolerability and activity of a rexinoid, bexarotene, combined with weekly paclitaxel and monthly carboplatin.

METHODS

Patients with confirmed advanced stage IIIB or IV NSCLC and adequate organ function were enrolled. They were scheduled to receive carboplatin (AUC =6) and 3 doses of weekly paclitaxel (100 mg/m2) every 4 weeks. Oral bexarotene was administered daily at two doses: 300 and 400 mg/m2/day.

RESULTS

Thirty-three patients were enrolled. Fourteen received 300 mg/m2/day and 19 received 400 mg/m2/day of bexarotene. Hematologic toxicity included grade 3 neutropenia in 7 patients. Hyperlipidemia was a major non-hematologic toxicity which was medically managed. The recommended phase II dose of bexarotene was 400 mg/m2/day. Response rate was 35%. Median overall survival (OS) for all patients was 8.3 months with 1-year survival of 43%. Median OS for the 300 mg/m2 dose of bexarotene was 6.6 versus 9.8 months for the 400 mg/m2 dose (HR, 0.73; Log rank P=0.37). Patients who experienced hypertriglyceridemia had a median OS of 9.8 months compared to 4.9 months for those who did not (HR, 0.69; Log rank P=0.33).

CONCLUSIONS

The 43% 1-year survival for patients receiving bexarotene with weekly paclitaxel and monthly carboplatin is encouraging. With the availability of new classes of agents for lung cancer, further evaluation of this regimen in unselected patients is not warranted. Our study confirms prior subgroup analyses showing a significant correlation between bexarotene-induced hypertriglyceridemia and survival. Further research is needed to identify molecular biomarkers to identify this subset of patients and to explore rexinoids in other combinations, especially with immunotherapy.

Assessing the Preparatory Grief in Advanced Cancer Patients (PGAC) instrument in an American population

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Background: Only 50% of cancer patients who screen positive on the Distress Thermometer accept referral to psychosocial resources and mainly for challenges coping with overwhelming emotional response to losses. The Preparatory Grief in Advanced Cancer (PGAC) instrument was shown to have significant associations with hopelessness, anxiety, and depression in a Greek population with favorable potential as a screening tool. We aimed to assess the use of the PGAC in a sample of American patients diagnosed with incurable cancer as a more efficient screening tool for patients who would benefit from additional psychosocial referrals. Methods: We conducted this survey with participants from Northwestern University in Chicago, IL. Participants were US citizens and >18 years old with an incurable cancer and no history of substance abuse or current psychiatric diagnosis. Patients were asked to complete a single survey composed of demographic data and scales including the PGAC, Distress Thermometer, HADS, ESAS and QOL. We used pair-wise correlation measurements, which included p-value measurements for testing whether the correlation coefficient was significantly different from 0. We then used pair-wise correlation coefficients to assess for p-value < 0.05 at different PGAC scores. Results: 53 patients were surveyed, of which 57% (30) were outpatients. The PGAC score was associated with the distress thermometer (R=0.74, p=<0.001), HADS (R=0.65, p=<0.01), and ESAS (R=0.49, p=<0.01) as well as inversely correlated with QOL score (R=-0.45, p=<0.001). Additionally, PGAC > 21 (p=0.02) was associated with elevated distress thermometer score (p=0.02) and elevated HADS scores (p=0.04). Conclusions: We tested the PGAC in an American population for the first time and found correlation between PGAC other validated measures (Distress Thermometer, ESAS, HADS, QOL) in an American population. We propose a PGAC cutoff of >21 to assess for preparatory grief due to its association with elevated scores on Distress and HADS scales above this threshold. This instrument may better identify patients struggling with coping who would benefit from additional support but further investigation is needed.