Subsequent Course Of Treatment Research Articles

Health-related quality of life and symptoms in patients with previously untreated, locally advanced or metastatic non-squamous non-small cell lung cancer treated with sintilimab or placebo plus pemetrexed and platinum (ORIENT-11): A randomized, double-blind, phase 3 trial.

In the phase 3 ORIENT-11 study, sintilimab plus pemetrexed-platinum provided statistically significant longer overall survival and progression-free survival versus placebo plus pemetrexed-platinum as first-line treatment in patients with locally advanced or metastatic non-squamous non-small cell lung cancer (NSCLC). Here, we report the patient-reported outcomes (PRO) analysis findings in ORIENT-11. PROs were measured using the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients Questionnaire Core 30 items (EORTC QLQ-C30) and the Lung Cancer Symptom Scale (LCSS) questionnaire. PRO endpoints included evaluation of least square (LS) mean changes from baseline to week 12 (platinum-containing treatment) and week 21 (maintenance treatment), time to true deterioration (TTD), and overall improvement or stability rate for QLQ-C30 and LCSS scales. PRO scores in two groups were compared using the Mann-Whitney test. Least squares (LS) mean changes from baseline to week 12, week 21, and other time points were assessed with mixed-effect model repeated measures analysis. TTD was calculated using the Kaplan-Meier method and compared with the Cox proportional hazards model between groups. 252 (94.7%) patients in the sintilimab-combination group and 123 (93.9%) patients in the placebo-combination group had a baseline and at least one postbaseline PRO assessment. Change from baseline to week 12 or 21 favored the sintilimab-combination group on QLQ-C30 global health status/quality of life (GHS/QoL), most function and symptoms scales, and most LCSS scales. Notably, the QLQ-C30 pain score change gradually deteriorated in the placebo-combination group with increased treatment. At the same time, it improved in the sintilimab-combination group significantly from 6weeks later, with the improvement sustained in subsequent courses of treatment. Sintilimab plus chemotherapy significantly delayed the TTD in most QLQ-C30 and LCSS scales compared with placebo plus chemotherapy, and the overall improvement or stability rates were higher in the former. The addition of sintilimab to chemotherapy maintained or improved health-related quality of life and symptoms compared with chemotherapy. Along with the previous efficacy and safety results, these data support the addition of sintilimab to standard chemotherapy as first-line therapy in locally advanced or metastatic non-squamous NSCLC. NCT03607539.

Long-term pharmacotherapy in patients with uterine myoma: assessment of effectiveness

BACKGROUND: Uterine myoma is one of the most prevalent gynecological diseases. Data concerning the effects of the medicinal agents used in patients with uterine leyomyomas, are both scientifically and practically important. AIM: This study aims to assess the clinical, laboratory, and instrumental effectiveness of 5-year use of micronized oral contraceptive containing estrogen and progestogen, intrauterine levonorgestrel-releasing system and progesterone receptor modulator in patients with uterine myoma. MATERIAL AND METHODS: Patients aged from 21 to 40 years old were assigned to 3 arms in accordance with the treatment regimen. Group 1 included 42 women with myomas ≤2 cm in diameter. These patients received combined oral contraceptive pills containing ethinylestradiol 20 mcg and desogestrel 150 mg according to the conventional contraceptive regimen, i.e. one pill daily, 21-day courses with following 7-day pauses. Group 2 included 34 women with uterine myoma and concomitant uterine endometriosis. In this group, the intrauterine devices containing levonorgestrel were inserted. Group 3 included 33 patients treated with the progesterone receptor modulator in order to reduce the diameter of uterine myomas. They received oral mifepristone at a dose of 50 mg daily for three months, followed by a 3-month pause and subsequent 3-month course of treatment. During the year, two cycles that included 3-month treatment course and 3-month treatment-free period, were repeated. All patients underwent standard clinical, laboratory and instrumental gynecological examination. Statistical processing was performed in the basis of Statistica 12.0 software. RESULTS: In Group 1, 80.9% of patients exhibited unchanged mean diameters of uterine myomas all over the course of treatment with contraceptive drugs, 16.7% of patients demonstrated growth of myoma (by 15%), while in 2.4% of patients myoma reduction (by 5%) was observed. In Group 2, the increase in the diameter of leiomyoma ranged from 20 to 30 percent was observed following the insertion of intrauterine levonorgestrel-releasing system in 58.8 percent of patients. In contrast, 35.3 percent of patients exhibited no change in myoma size, while a decrease by 15 percent was observed in only 5.9 percent of patients. In Group 3, 10 intermittent 3-month courses of mifepristone (50 mg) resulted in the reduction of uterine myoma by 40%–50% of the baseline diameter in 97.0% of patients. In general, the study drugs demonstrated beneficial effects and safety in patients with leiomyoma. CONCLUSION: The long-term use of low-dose oral contraceptives generally leads in the stabilization of the size of uterine myomas, while intrauterine levonergestrel-releasing system prevents their intensive growth. Nevertheless, the use of a drug belonging to the progesterone receptor modulator class, has proven to be the most effective approach to reducing the size of myomas.

Relapse-free survival is progressively shortened in a subset of Black patients with immune-mediated TTP treated in the rituximab era.

Immune thrombotic thrombocytopenic purpura (iTTP) is a chronically relapsing disorder caused by autoantibody-mediated deficiency of ADAMTS13. Rituximab is frequently administered to prevent relapses, but whether the durability of rituximab effect is maintained with subsequent treatment courses has not been studied. Using the United States Thrombotic Microangiopathy Consortium (USTMA) retrospective iTTP registry, we evaluated clinical relapse-free survival (RFS) with subsequent courses of rituximab treatment in multiply relapsing patients. Separately, we evaluated overall RFS (composite of time to clinical relapse, ADAMTS13 relapse, or preemptive rituximab) in a prospective iTTP cohort from the Johns Hopkins University and the University of Minnesota. In the USTMA registry, median clinical RFS was shorter after the second or subsequent rituximab-treated episode than the first (2.1 vs 6.0 years; P=.04). White patients' clinical relapse risk after the second and subsequent rituximab courses was not significantly different compared with the first (hazard ratio [HR], 1.86; 95% confidence interval [CI], 0.22-15.80; P=.57), whereas for Black patients, clinical relapse risk was significantly higher after the second or subsequent courses (HR, 2.82; 95%CI, 1.52-5.24; P=.001). In the prospective cohort, overall RFS progressively shortened after each episode of rituximab treatment with the first episode having the longest RFS (2.8 years; interquartile range, 2.0-6.0) and this loss of response durability was most pronounced in Black patients. The durability of rituximab's effect declines with subsequent treatments, which is more pronounced in Black patients, who may benefit from closer monitoring and alternative immunomodulatory approaches such as maintenance rituximab and consideration of other agents.

Chinese expert consensus on short duration infusion of obinutuzumab (2024)

Obinutuzumab has been widely used in patients with CD20 positve B-cell non-Hodgkin's lymphoma for more than 10 years since its launch, bringing significant clinical benefits. At present, studies at home and abroad have confirmed that the 90-minute short duration infusion of obinutuzumab is safe and feasible.In order to improve the convenience of patient infusion and the efficiency of medical institutions'infusion facilities, it is recommended for patients who do not experience grade ≥3 infusion-related adverse reactions in the first cycle of obinutuzumab infusion at the standard rate, a short duration infusion scheme should be used for subsequent treatment courses. This expert consensus is formulated to provide guidance for clinical practice.

Management of Uveitis Patients on Anti-TNF Agents Who Develop Demyelinating Disease – A Case Series

Background/AimsAnti-tumor necrosis factor (Anti-TNF) agents have proven beneficial for the treatment of chronic non-infectious uveitis, yet rare neurological complications and demyelinating disease can occur with their use. Management of uveitis and neurological disease after developing these rare complications is not well understood. We sought to identify these specific cases and their outcomes through a retrospective observational case series.MethodsElectronic Medical Record (EMR) chart review of 394 non-infectious uveitis patients on anti-TNF therapy focused on identifying patients seen by uveitis specialists at a single institution who were on anti-TNF therapy and had developed neurological symptoms. Cases were reviewed for subsequent management and outcomes of both their neurologic and ocular inflammatory disease.ResultsFive (5) patients were included following complaints of neurological symptoms while on anti-TNF therapy. Subsequent demyelinating diagnosis, acute treatment, and long-term course were described. All five patients continue to be inactive at around three years of anti-TNF discontinuation.ConclusionUnidentified rare neurological symptoms and demyelinating disease associated with the use of anti-TNF agents can be detrimental to patient treatment outcomes. Emphasis is given on possible avoidance and early identification of exacerbating underlying disease through a detailed neurologic history and use of imaging when suspicion is high. Patients may have no evidence of higher neurological risk prior to starting an anti-TNF treatment. Discontinuation of an anti-TNF agent and subsequent control of disease is possible with alternative immunosuppressive treatments.

Predicting Outcome in Clear Aligner Treatment: A Machine Learning Analysis.

Background/Objectives: Machine learning (ML) models predicting the risk of refinement (i.e., a subsequent course of treatment being necessary) in clear aligner therapy (CAT) were developed and evaluated. Methods: An anonymized sample of 9942 CAT patients (70.6% females, 29.4% males, age range 18-64 years, median 30.5 years), as provided by DrSmile, a large European CAT provider based in Berlin, Germany, was used. Three different ML methods were employed: (1) logistic regression with L1 regularization, (2) extreme gradient boosting (XGBoost), and (3) support vector classification with a radial basis function kernel. In total, 74 factors were selected as predictors for these methods and are consistent with clinical reasoning. Results: On a held-out test set with a true-positive rate of 0.58, the logistic regression model has an area under the ROC curve (AUC) of 0.67, an average precision (AP) of 0.73, and Brier loss of 0.22; the XGBoost model has an AUC of 0.67, an AP of 0.74, and Brier loss of 0.22; and the support vector model has a recall of 0.61 and a precision of 0.64. The logistic regression and XGBoost models identify predictors influencing refinement risk, including patient compliance, interproximal enamel reduction (IPR) and certain planned tooth movements, for example, lingual translation of maxillary incisors being associated with the lowest risk of refinement and rotation of mandibular incisors with the highest risk. Conclusions: These findings suggest moderate, well-calibrated predictive accuracy with both regularized logistic regression and XGBoost and underscore the influence the identified factors have on the risk of refinement in CAT, emphasizing their importance in the careful planning of orthodontic treatment and the potential for shorter treatment times, less patient discomfort, and fewer clinic visits. Identification of at-risk individuals could support tailored clinical decision-making and enable targeted interventions.

A VERY COMPLEX CASE OF DORV TYPE FALLOT: A CASE REPORT

Abstract Double outlet right ventricle (DORV) is a rare CHD characterized by ventriculoarterial connection in which both great arteries arise entirely or predominantly from the right ventricle. Its prevalence is 0.9% of all CHDs. Several chromosomal abnormalities have been associated with DORV, including trisomy 13, trisomy 18, and chromosome 22q11 deletion. Hearts with DORV are an extremely heterogeneous group showing various morphological features, connections, and relationships at each level of the cardiac segments and intersegmental junctions. As a consequence, the clinical manifestations and required surgical procedures for patients with DORV are variable. The anatomical spectrum is higly variable: it can be associated with ventricular septal defect, transposition of the great arteries (TGA) and functional single ventricle. We report the case of an infant with prenatal diagnosis of CHD and finding partial duplication of the short arm of the X chromosome. Pregnant woman at 22 weeks comes to the outpatient clinic to perform follow–up ultrasound. At that site finding of CHD which was later confirmed at birth and therefore prostaglandin therapy was started. Echocardiogram showed a wide DIV from malalignment with antero–cephalic deviation of the conal septum with significant aortic destroposition configuring picture of double outlet right ventricle. It also presents a complex right efflux obstruction already at subvalvular pulmonary departure. The pulmonary valve presented dysplastic, with en dome motion, hypoplastic. Pulmonary perfusion appears to be provided predominantly by the Botallo‘s duct originating from the isthmic region of the aorta and leading with a long and tortuous course to the pulmonary confluence near the left pulmnary artery with high velocity flow. The remaining findings are normal. Therefore, in view of the clinical picture, he was subjected to palliative surgery of right systemic–pulmonary shunt between the brachiocephalic trunk and right pulmonary artery (modified Blalock–Taussing surgery) in 3.5mm PTFE and ligation of Botallo‘s duct. At subsequent follow–up, the systemic–pulmonary shunt appeared pervious with regular flow. Wide DIV from anterior malalignment with aorta cavalier to DIV. Severe stenosis at complex pulmonary outflow with max gradient up to 124mmHg with dynamic and valvular component. For the subsequent course of treatment, the patient will be discussed collegially.

Sequential Acute Courses of Transcranial Magnetic Stimulation in Major Depressive Disorder: A Retrospective Analysis in a Veteran Cohort

BackgroundRepetitive transcranial magnetic stimulation (TMS) is now widely accepted as an effective non-pharmacologic treatment for treatment-resistant depression. However, whether repeated acute TMS courses can recapture the antidepressant effects of the initial acute course is still an open question, especially in the Veteran population. We present here a retrospective analysis of a specialty clinic within the Veteran Affairs Hospital System to help address this question. AimsFollowing an acute treatment course of TMS, we sought to determine the treatment response of a subsequent TMS course. We hypothesized that those who responded to an initial acute TMS course would respond in a similar manner to a subsequent treatment course. Methods116 cases referred for evaluation for TMS between September 2017 to April 2021 were reviewed. 63 Veterans completed at least one acute course of TMS and 12 completed at least two courses and met inclusion criteria for this review. 6 met criteria for treatment response in the first course, while the other 6 were initial treatment nonresponders. Symptoms were evaluated via self-reported scales at baseline and weekly throughout treatment. Clinical response to subsequent treatment (>50% symptom reduction as measured by the PHQ-9) was compared to initial treatment response. ResultsOf the initial treatment responders (n = 6), all six responded to a second acute course, with an 85.3% symptom reduction. Of the initial treatment nonresponders (n = 6), three responded to a second acute course. No adverse events were reported in those who completed a second course, and the Veterans tolerated the treatment well. ConclusionsOur findings support the growing understanding that a second acute TMS treatment course for treatment-resistant depression is safe, well-tolerated, and effective in initial responders and some non-responders. Despite multiple confounders in a naturalistic setting, robust initial treatment response was sustained in a second acute course. Low power limits generalizability, and larger powered, prospective studies are needed.

Exploratory analysis of serum HER2 extracellular domain for HER2 positive gastric cancer treated with SOX plus trastuzumab.

The aim of this study was to explore the clinical utility of serum HER2 extracellular domain (sHER2 ECD) using data from a clinical trial evaluating trastuzumab combined S-1 plus oxaliplatin (SOX) in HER2 positive gastric cancer. sHER2 ECD were prospectively measured at baseline and subsequent treatment courses. Based on each quantile point of baseline sHER2 ECD levels and its early changes, patients were divided into two groups and compared clinical outcomes. 43 patients were enrolled, and 17 patients (39.5%) were positive for baseline sHER2 ECD. Higher baseline sHER2 ECD levels tended to have lower hazard ratios (HRs). When divided into two groups by baseline sHER2 ECD of 19.1ng/ml, median progression-free survival (PFS) and overall survival (OS) was longer in the higher group (mPFS: 16.8 vs 8.7months, p = 0.359. mOS: 35.5 vs 20.6months, p = 0.270), respectively. After initiation of treatment, sHER2 ECD significantly decreased up until the third cycle. Higher reduction rates of sHER2 ECD within 3 cycles also tended to have lower HRs. When divided into two groups by reduction rate of 42.5%, mPFS and mOS was longer in the higher reduced group (mPFS: 17.2 vs 8.7months, p = 0.095. mOS: 65.0 vs 17.8months, p = 0.047), respectively. Furthermore, higher reduction rates could surrogate higher objective response rates (ORR) (ORR: 90% vs 63.2% for 29.5%, p = 0.065. 100% vs 70% for 42.5%, p = 0.085), respectively. Baseline sHER2 ECD levels and its early decline may be useful biomarkers for SOX plus trastuzumab efficacy in HER2 positive gastric cancer.

The Potential of Repeated Application of β-Glucans in Patients with Chronic Obstructive Pulmonary Disease and the Comparative Effectiveness of Subsequent Treatment Courses

The Potential of Repeated Application of β-Glucans in Patients with Chronic Obstructive Pulmonary Disease and the Comparative Effectiveness of Subsequent Treatment Courses

Real-world Experiences in the Transplantation of Hepatitis C-NAAT-positive Organs.

Hepatitis C virus (HCV) nucleic acid amplification test (NAAT)-positive donors have increased the organ pool. Direct-acting antivirals (DAAs) have led to high rates of treatment success and sustained virologic response (SVR) in recipients with donor-derived HCV infection without significant adverse effects, although variability remains in the timing and duration of antivirals. This retrospective study analyzed all adult HCV-NAAT-negative transplant recipients who received an organ from HCV-NAAT-positive donors from November 24, 2018, to March 31, 2022, at Duke University Medical Center with protocolized delay of DAA initiation until after hospital discharge, with at least 180-d follow-up on all patients. Transplant and HCV-related outcomes were analyzed. Two hundred eleven transplants (111 kidneys, 41 livers, 34 hearts, and 25 lungs) were performed from HCV-NAAT-positive donors to HCV-NAAT-negative recipients. Ninety percent of recipients became viremic within 7 d posttransplant. Ninety-nine percent of recipients were initiated on pangenotypic DAAs in the outpatient setting a median of 52 d posttransplant, most commonly with 12-wk courses of sofosbuvir-velpatasvir (lungs) and glecaprevir-pibrentasvir (heart, kidney, and liver). Ninety-seven percent of recipients had SVR after a first-line DAA; all ultimately achieved SVR at 12 wk after subsequent treatment courses. The median peak HCV RNA for all organ systems was 2 436 512 IU/mL; the median time from antiviral to undetectable RNA was 48 d, although differences were noted between organ groups. No patient deaths or graft losses were directly attributable to HCV infection. One hundred percent of transplant recipients of HCV-NAAT-positive organs ultimately developed SVR without significant adverse effects when HCV antivirals were initiated in the outpatient setting after transplant hospitalization, suggesting that this real-world treatment pathway is a viable option.

FRI225 Clinical Course Of Late-onset Adrenal Insufficiency Due To Treatment Of Childhood Acute Lymphoblastic Leukemia

Abstract Disclosure: M. Iwabuchi: None. Background: Some people who were treated for cancer during childhood may develop endocrine problems as because of changes in the function of endocrine system. Acute lymphoblastic leukemia is the most common type of cancer and leukemia in children and components of ALL treatment are induction, consolidation, maintenance, and central nervous system prophylaxis. It is recommended that people who had irradiation in a dose of 40 Gy or higher to the central area of the hypothalamic-pituitary axis should have a blood test done to check the cortisol level and should be done yearly for at least 15 years since this complication can occur many years after irradiation. Clinical Case: A man in his 40s was admitted with symptoms of diarrhea, low-grade fever, and drowsiness. The serum sodium level that caused his symptoms decreased to 100 mEq/L and was adequately corrected. Endocrinological examination confirmed the diagnosis of central adrenal insufficiency. Soon after starting hormonal replacement therapy with hydrocortisone, his general conditions improved. After establishing our relationship, he confessed to having a history of ALL in childhood. According to his medical records at the time, he underwent induction therapy with vincristine-prednisone in 1977, maintenance therapy with 6-mercaptopurine, and radiation therapy to the central nervous system of 25 Gy in 1983. In 2023, 40 years have passed since radiation therapy. He was able to lead a normal life on oral hydrocortisone 20 mg/day without recurrence of adrenal insufficiency. Clinical Lesson: A 40-old male survivor of ALL developed adrenal insufficiency in 30 years after cranial irradiation during childhood. Undiagnosed adrenal insufficiency is often the cause of death. We should consider childhood cancer survivors have the risk of a central adrenal insufficiency. The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (COG LTFU Guidelines) are a resource for healthcare professionals who provide ongoing care to survivors of pediatric malignancies. The screening recommendations in these guidelines are appropriate for asymptomatic survivors of childhood, adolescent, or young adult cancer presenting for routine exposure-based medical follow-up. It is recommended that people who had irradiation in a dose of 40 Gy or higher to the central area of the hypothalamic-pituitary axis should have a blood test done to check the cortisol level and should be done yearly for at least 15 years since this complication can occur many years after irradiation. This case highlights the importance of long-term follow-up of cancer survivors after irradiation and the delayed presentation of adrenal insufficiency. This is the first report of the subsequent treatment course of late-onset adrenal insufficiency that developed 30 years after irradiation for childhood central nervous system ALL. Presentation: Friday, June 16, 2023

In-Office Amoxicillin to Increase Graded-Dose Challenges at Initial Evaluation for Penicillin Allergy.

More than 90% of pediatric patients labeled with a penicillin allergy can tolerate subsequent treatment courses without reaction. Graded-dose challenges (GDCs) are an important tool to clarify reported penicillin allergy. To increase the use of same-day amoxicillin GDCs among patients with a low-risk penicillin allergy history who presented for outpatient allergy office evaluation from 2% to 15% and sustain for 6 months. New patients evaluated in an academic pediatric allergy clinic with a documented penicillin allergy were included, regardless of reason for referral. The percentage of these patients who were administered a GDC to amoxicillin at the initial evaluation was assessed over time. Multiple interventions were implemented to increase same-day GDC: amoxicillin, previously only available from pharmacy, was made available in clinic, and penicillin-allergic patients were scheduled earlier in the clinic session. The baseline rate of new patients with penicillin allergy who received a GDC increased from 2% to 18% after amoxicillin was stocked in the allergy clinic. GDCs further increased to 34% after penicillin-allergic patients were scheduled at a time conducive to challenge. Amoxicillin availability in the clinic setting increased the percentage of eligible patients who completed same-day GDCs. Scheduling adjustments further increased the ability to conduct GDCs. Proactive penicillin allergy delabeling efforts can be assisted through practical approaches in the outpatient setting.

Beyond the 5-year milestone: Long-term survivorship of melanoma patients treated off-trial with anti-PD-1.

Little is known about the long-term outcomes of anti-PD-1 treated patients with melanoma beyond 5 years, especially for patients treated off clinical trials. This retrospective cohort study includes patients with unresectable stage III/IV nonuveal melanoma treated with anti-PD-1 off-trial at Memorial Sloan Kettering Cancer Center between 2014 and 2017 who survived at least 5 years following their first anti-PD-1 dose (N=139). We characterized overall survival (OS), melanoma-specific survival (MSS) estimates, treatment-free survival rates, and subsequent treatment courses. Median follow-up among 5-plus year survivors (N=125) was 78.4 months (range 60.0-96.3). OS at year 7 (2 years post 5-year landmark) was 90.1% (95% CI: 83.0%-94.3%). Fourteen deaths occurred, seven due to melanoma. MSS at year 7 (2 years post 5-year landmark) was 95.0% (95% CI: 33.5%-95.2%). In patients who completed anti-PD-1 based therapy and did not require subsequent treatment by 5 years (N=80), the probability of not requiring additional treatment for an additional 2 years was 95.7% (95% CI: 91.0%-100%). Patients treated with anti-PD-1 regimens off clinical trials who survive at least 5 years from initial anti-PD-1 treatment can be reassured of their excellent long-term prognosis, particularly if they did not require additional melanoma treatment during the first 5 years.

Elderly onset atypical Lemierre’s syndrome concurrent with a rheumatoid vasculitis sacral ulcer infection: a case report

BackgroundTypical Lemierre’s syndrome is usually secondary to an oropharyngeal infection. Recently, several cases following a primary infection site other than the oropharynx have been reported as atypical Lemierre’s syndrome; although, these primary lesions are limited to the head and neck. This is the first case potentially sequential to infectious foci outside the head and neck.Case presentationWe describe an atypical Lemierre’s syndrome in a 72-year-old woman with rheumatoid arthritis, which occurred during the treatment of Streptococcus anginosus bacteremia acquired from a sacral ulcer infection related to rheumatoid vasculitis. At first, the symptoms resolved after the initial administration of vancomycin for the bacteremia caused by methicillin-resistant Staphylococcus aureus and Streptococcus anginosus that entered via a sacral ulcer. On the 8th day, the patient developed a fever of 40 °C and unexpectedly required 10 L of oxygen due to rapid deterioration of oxygenation temporarily. Immediately contrast-enhanced computed tomography was performed to investigate systemic thrombosis including pulmonary embolism. Afterward, the newly formed thrombi at the right external jugular vein, bilateral internal jugular veins, and the right small saphenous vein were detected, and apixaban was started. On the 9th day, the patient again had an intermittent fever of 39.7 °C, and continuous Streptococcus anginosus bacteremia was revealed; subsequently, clindamycin was administered. On the 10th day, she developed a left hemothorax; consequently, apixaban was discontinued, and a thoracic drain was inserted. She repeatedly had an intermittent fever of 40.3 °C, and contrast-enhanced computed tomography detected an abscess formation at the left parotid gland, pterygoid muscle group, and masseter muscle. After Lemierre’s syndrome was diagnosed in combination with the abovementioned jugular vein thrombus, clindamycin was replaced with meropenem, and vancomycin was increased. Swelling of the lower part of the left ear became prominent with delay and peaked at approximately the 16th day. The subsequent treatment course was favorable, and she was discharged on the 41st day.ConclusionClinicians should consider Lemierre’s syndrome as the differential diagnosis of internal jugular vein thrombosis occurring during sepsis, even though an antibiotic is administered or a primary infection site is anything besides the oropharynx.

Exploring patient experiences after treatment of humeral shaft fractures: A qualitative study

IntroductionHumeral shaft fracture treatment can induce serious morbidities, and it is unclear how these morbidities impact patients. To gain in-depth knowledge, we explored how patients experience humeral shaft fractures and the subsequent treatment course. MethodA qualitative study was performed using semi-structured individual interviews. A purposive sampling approach was conducted to recruit patients with traumatic isolated humeral shaft fractures; the patients’ ages, genders, primary treatments, and complications varied. Data saturation was met after the data of 12 patients were analyzed using Malterud Systematic Text Condensation. ResultsEight women and four men with a median age of 48.5 years (range: 22–83 years) were interviewed. The median time from injury to interview was 12.5 months (range: 8–18 months). Ten out of twelve patients were treated non-surgically; of those ten, four patients experienced major complications from the primary treatment. During the analysis, five overarching themes appeared: expectations, physical changes, support and independence, psychological impact, and the specific treatment and recovery. ConclusionFirst, patients with humeral shaft fractures expressed frustration with treatment in the emergency department. Second, gross fracture movement and pain were central symptoms that led to the loss of basic capabilities. Third, patient preferences were included in the treatment decision-making process and could change throughout the treatment course. Fourth, patients required massive support to perform basic activities of daily living.

Quantifying Empiric Antibiotic Use in US Children's Hospitals.

Empirical broad-spectrum antibiotics are routinely administered for short durations to children with suspected bacteremia while awaiting blood culture results. Our aim for this study was to estimate the proportion of broad-spectrum antibiotic use accounted for by these "rule-outs." The Pediatric Health Information System was used to identify children aged 3 months to 20 years hospitalized between July 2016 and June 2017 who received broad-spectrum antibiotics for suspected bacteremia. Using an electronic definition for a rule-out, we estimated the proportion of all broad-spectrum antibiotic days of therapy accounted for by this indication. Clinical and demographic characteristics, as well as antibiotic choice, are reported descriptively. A total of 67 032 episodes of suspected bacteremia across 42 hospitals were identified. From these, 34 909 (52%) patients were classified as having received an antibiotic treatment course, and 32 123 patients (48%) underwent an antibiotic rule-out without a subsequent treatment course. Antibiotics prescribed for rule-outs accounted for 12% of all broad-spectrum antibiotic days of therapy. Third-generation cephalosporins and vancomycin were the most commonly prescribed antibiotics, and substantial hospital-level variation in vancomycin use was identified (range: 16%-58% of suspected bacteremia episodes). Broad-spectrum intravenous antibiotic use for rule-out infections appears common across children's hospitals, with substantial hospital-level variation in the use of vancomycin in particular. Antibiotic stewardship programs focused on intervening on antibiotics prescribed for longer durations may consider this novel opportunity to further standardize antibiotic regimens and reduce antibiotic exposure.

Course of postoperative relapse in non-small cell lung cancer is strongly associated with post-progression survival.

BackgroundFor early‐stage non‐small cell lung cancer (NSCLC), surgical resection is considered the most effective treatment strategy and curative treatment. Unfortunately, even after complete resection, almost half of all patients with stage I–IIIA NSCLC relapse and die. Although the possibility of a cure for postoperative recurrence of NSCLC is significantly low, the course of subsequent treatment can possibly affect overall survival (OS). Here, we examined the association of relapse‐free survival (RFS) and post‐progression survival (PPS) with OS in patients with postoperative recurrence of NSCLC.MethodsWe evaluated 128 patients with NSCLC who underwent complete resection between January 2007 and December 2018. The association between RFS and PPS on OS was examined at the patient level.ResultsSpearman's rank correlation and linear regression analyses revealed that PPS was strongly correlated with OS (r = 0.83, p < 0.05, R 2 = 0.72), whereas RFS was weakly associated with OS (r = 0.56, p < 0.05, R 2 = 0.37). Additionally, the performance status at relapse and administration of tyrosine kinase inhibitors were significantly correlated with PPS.ConclusionsPPS was significantly more strongly correlated with OS than was RFS in patients with postoperative recurrence of NSCLC. These results suggest that therapy following postoperative recurrence affects OS. Therefore, it is necessary to validate these promising results in a large prospective study.

What Is the Clinical Impact of Sending Tissue for Histopathology During Surgery for Known, Diffuse Metastatic Disease to Bone?

During surgery for patients with known, diffuse metastatic bone disease (MBD), lesional tissue is routinely sent for pathological evaluation. However, there are limited data to assess whether there is a role for histopathology for MBD despite time and cost of interpretation, as well as whether a positive sample changes the subsequent treatment course. Sixty-six cases from 2017 to 2020 were reviewed retrospectively. The median age at surgery was 63.5 years (range of 23 to 84 years), and the primary tumor was most frequently breast (24.2%, n=16), renal (21.2%, n=14) or lung (15.2%, n=10). The most common location of MBD was the femur (60.6%, n=40). The overall yield of a positive tissue sample of MBD was 77.3% (n=51). The positive rate from sending intramedullary reamings was 65.4% (n=17 of 26). Among the 66 cases (63 patients), a change in the subsequent clinical management was recorded in 9.1% (n=6). The most common change was related to the medication regimen (n=5), with one change related to recognition of the carcinoma origin via histology, which was previously unknown. Despite the routine practice of sending tissue for histology during surgery for known and diffuse MBD, a change in the subsequent clinical management is uncommon. Prior to sending tissue, surgeons should discuss this practice with the multidisciplinary care team on a per-patient basis.

Alternative Diagnoses in Pediatric Fecal Microbiota Transplant Referral Patients.

The incidence of Clostridioides difficile infection (CDI) has been increasing in the United States. About 10-20% recur after initial treatment, with increasing recurrence following subsequent treatment courses. This sequence can lead to recurrent CDI (rCDI), refractory to conventional therapeutics resulting in the most common indication for fecal microbiota transplantation (FMT). FMT is the most effective microbial therapeutic to date and can cure rCDI in 80-90% of cases. There is growing concern, however, for pathogen transmission through FMT, underscoring the importance of careful recipient selection. In adults referred for FMT with a tentative diagnosis of rCDI, alternative diagnoses were recognized in 25% of patients, but such observation in children is lacking. In this single-center retrospective study, alternative diagnoses (eg, constipation/overflow diarrhea, inflammatory bowel disease) were found in 13 (22.4%) of 58 children who were referred for FMT evaluation for rCDI. Of the patients who were diagnosed with rCDI, 16 (27.6%) did not require FMT.