Variation In Duration Of Treatment Research Articles

P-367 Letrozole or Tamoxifen co-administration during fertility preservation of breast cancer patients: a retrospective cohort study

Abstract Study question How do fertility preservation (FP) outcomes differ between breast cancer patients stimulated with FSH and Tamoxifen versus FSH and Letrozole? Summary answer Letrozole and Tamoxifen co-administration yielded similar number of retrieved and cryopreserved oocytes/embryos, as well as similar oocyte maturation and fertilization and rates. What is known already Oocyte/embryo cryopreservation is recommended before initiation of chemotherapy in cancer patients. The co-administration of Tamoxifen, a selective estrogen receptor modulator, or Letrozole, an aromatase inhibitor, during ovarian stimulation with gonadotropins, are used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the optimal choice between the two is still unclear and with no sound evidence. Study design, size, duration Retrospective cohort study of all FP treatments of newly diagnosed breast cancer patients in two tertiary centers between 2000-2022. Collected data included 354 FP cycles of 290 patients and compared treatment parameters and outcomes of Tamoxifen or Letrozole co-administration. Participants/materials, setting, methods Breast cancer patients who underwent FP before chemotherapy were included. Patients with a history of radiation or gonadotoxic treatment, as well as those undergoing other fertility preservation treatments, such as ovarian tissue cryopreservation were excluded. Main results and the role of chance Overall, 215 Letrozole and 139 Tamoxifen treatment cycles were compared, with no significant demographic differences. Treatments with Letrozole had higher FSH dosages (3970IU vs. 2839IU, p < 0.001) but shorter duration (9.7 vs. 10.5 days, p < 0.001). The Letrozole group achieved lower peak E2 levels and endometrial thickness (1508pmol/L, 8.1mm vs. 8760pmol/L, 9.5mm, p < 0.001). The mean number of retrieved oocytes was comparable between the groups (13.6 with Letrozole vs 14.7 with Tamoxifen, p = 0.06). In 122 Letrozole and 46 Tamoxifen patients that underwent strictly oocytes cryopreservation the mean number of cryopreserved oocytes was comparable (11 vs. 12.1, p = 0.21). Moreover, in embryo cryopreservation cycles of 71 patients treated with Letrozole compared to 76 patients with Tamoxifen, no difference was observed in the number of cryopreserved embryos (6.2 vs. 7.0, p = 0.12). Oocyte maturation rate among strictly oocyte preservation cycles was comparable (86% with Letrozole vs. 83% with Tamoxifen, p = 0.80), as were fertilization rates in embryo cryopreservation cycles (62% vs. 63%, p = 0.8 and 71% vs. 76%, p = 0.3 in IVF and ICSI with Letrozole and Tamoxifen, respectively). Multivariate analysis, controlling for potential confounders showed no significant correlations between Tamoxifen or Letrozole co-administration and the number of retrieved oocytes or oocyte maturation rate. Limitations, reasons for caution The primary limitation of our study is its retrospective design and the variation in treatment duration and gonadotrophin dosages among groups. Wider implications of the findings This study provides reassurance that both Tamoxifen and Letrozole are equally effective options when co-administered in FP treatments of breast cancer patients. Trial registration number not applicable

Fungal skin infections

Fungal infections of the skin continue to place a burden on healthcare services. Margaret Perry provides an overview of the most common conditions Fungal infections of the skin continue to place a burden on healthcare and are a significant issue globally in terms of their cost and impact on resources. Some are more difficult to treat than others and there is a wide variation in duration of treatment, depending on the site and severity. Many fungal infections share similarities in appearance with other skin conditions, which can sometimes make diagnosis difficult. This article details some of the most common conditions and aims to give nurses and non-medical prescribers an overview of evidence-based treatment and management as well as to increase confidence when managing some of these troublesome diseases.

Fungal skin infections

Fungal infections of the skin continue to place a burden on healthcare and are a significant issue globally in terms of their cost and impact on resources. Some are more difficult to treat than others and there is a wide variation in duration of treatment, depending on the site and severity. Many fungal infections share similarities in appearance with other skin conditions, which can sometimes make diagnosis difficult. This article details some of the most common conditions and aims to give nurses and non-medical prescribers an overview of evidence-based treatment and management as well as to increase confidence when managing some of these troublesome diseases.

Routine treatment duration for clients attending a community based anxiety disorders clinic.

To determine the average duration of treatment at a community-based anxiety disorders clinic. Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients. The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1-128, range for treatment duration = 0-186 weeks). Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.

Benefit of Treatment Individualization in Patients with Chronic Hepatitis C Receiving Peginterferon Alfa-2a and Ribavirin in a Large Noninterventional Cohort Study.

Background and AimsIndividualization of treatment with peginterferon alfa and ribavirin in patients with chronic hepatitis C showed benefit in controlled trials and was implemented in treatment guidelines to increase response rates and to reduce side effects and costs. However, it is unknown whether individualization was adopted in routine daily practice and whether it translated into improved outcomes.MethodsFrom a large noninterventional cohort study, clinical and virologic response data of 10,262 HCV patients who received peginterferon alfa-2a and ribavirin between 2003-2007 and 2008-2011 were analyzed. To account for treatment individualization, a matched-pair analysis (2,997 matched pairs) was performed. Variation in treatment duration and dosing of ribavirin were analyzed as indicators for individualization.ResultsSustained virological response (SVR) rates were similar between 2003-2007 and 2008-2011 (62.0% vs. 63.7%). Patients with comorbidities were more abundant in the later period, (44.3% vs. 57.1%). The subsequent matched-pair analysis demonstrated higher SVR rates in the 2008-2011 period (64.3%) than in the 2003-2007 period (61.2%, p=0.008). More patients received abbreviated or extended treatment regimens in the later than the earlier period as an indicator of treatment individualization. To the same end, ribavirin doses were higher in the later period (12.6 versus 11.6 mg/kg/day). Factors independently associated with SVR included HCV genotype, low baseline viral load, younger age, route of infection, absence of concomitant diseases, lower APRI score, normal gamma-GT, higher ribavirin doses, no substitution for drug abuse, treatment duration, and treatment in the 2008-2011 period.ConclusionsTreatment individualization with peginterferon alfa and ribavirin was implemented in daily routine between 2003-2007 and 2008-2011, SVR rates improved in the same period. These findings may be most relevant in resource-limited settings.

Cost per median overall survival month for abiraterone acetate and enzalutamide for treatment of patients with metastatic castration-resistant prostate cancer (mCRPC).

e16080 Background: Phase 3 trials of abiraterone acetate plus prednisone (AA+P) or enzalutamide (ENZ) in asymptomatic/mildly symptomatic chemotherapy-naive mCRPC patients demonstrated significant improvement in overall survival (OS). Clinical trials comparing the magnitude of OS benefit for AA+P to ENZ have not been completed. In the absence of head-to-head trials, indirect comparisons may be used to assess the cost effectiveness of these agents in mCRPC. To calculate the cost per median OS month in asymptomatic/mildly symptomatic chemotherapy-naive mCRPC patients treated with AA+P or ENZ. Methods: Median treatment duration and median OS data from published phase 3 trials and prescribing information (PI) were used to calculate cost per median OS month based on Wholesale Acquisition Costs (WAC) effective on 8/5/2014 for mCRPC patients treated with AA+P versus ENZ. Sensitivity analyses were performed to understand how variation in treatment duration and treatment-related monitoring recommendations influence...

The index ‘Treatment Duration Control’ for enabling randomized controlled trials with variation in duration of treatment of chronic pain patients

BackgroundTreatment duration varies with the type of therapy and a patient’s recovery speed. Including such a variation in randomized controlled trials (RCTs) enables comparison of the actual therapeutic potential of different therapies in clinical care. An index, Treatment Duration Control (TDC) of outcome scores was developed to help decide when to end treatment and also to determine treatment outcome by a blinded assessor. In contrast to traditional Routine Outcome Monitoring which considers raw score changes, TDC uses relative change.MethodsOur theory shows that if a patient with the largest baseline scores in a sample requires a relative decrease by treatment factor T to reach a zone of low score values (functional status), any patient with smaller baselines will attain functional status with T. Furthermore, the end score values are proportional to the baseline. These characteristics concur with findings from the literature that a patient’s assessment of ‘much improved’ following treatment (related to attaining functional status) is associated with a particular relative decrease in pain intensity yielding a final pain intensity that is proportional to the baseline. Regarding the TDC-procedure: those patient’s scores that were related to pronounced signs and symptoms, were selected for adaptive testing (reference scores). A Contrast-value was determined for each reference score between its reference level and a subsequent level, and averaging all Contrast-values yielded TDC. A cut-off point related to factor T for attaining functional status, was the TDC-criterion to end a patient’s treatment as being successful. The use of TDC has been illustrated in RCT data from 118 chronic pain patients with myogenous Temporomandibular Disorders, and the TDC-criterion was validated.ResultsThe TDC-criterion of successful/unsuccessful treatment approximated the cut-off separating two patient subgroups in a bimodal post-treatment distribution of TDC-values. Pain intensity decreased to residual levels and Health-Related Quality of Life (HRQoL) increased to normal levels, following successful treatment according to TDC. The post-treatment TDC-values were independent from the baseline values of pain intensity or HRQoL, and thus independent from the patient’s baseline severity of myogenous Temporomandibular Disorders.ConclusionsTDC enables RCTs that have a variable therapy- and patient-specific duration.

Factors associated with duration of new antidepressant treatment: analysis of a large primary care database

It is not known how much the duration of newly prescribed antidepressant treatment is influenced by patient characteristics or practice variation. To describe the relationship between patient characteristics and the duration of new antidepressant treatment by general practices. Large primary care database cohort study of all patients with a newly initiated course of eligible antidepressant treatment during 1 year, from a database of 237 Scottish practices. Detailed prescription data were used to estimate the duration of new antidepressant treatment for each patient. Cox proportional hazards regression was used to estimate the influence of patient characteristics on continuation of treatment and, by multilevel modelling, the variation between practices. A total of 28 027 (2.2%) patients commenced antidepressant treatment during the year; 75% continued beyond 30 days, 56% beyond 90 days, and 40% beyond 180 days. Treatment was less likely to be continued in patients from areas of high socioeconomic deprivation: hazard ratio 1.22 (95% confidence interval [CI] = 1.16 to 1.29); in patients under 35 years, 1.33 (95% CI = 1.28 to 1.37); and in those for whom the GP recorded no relevant diagnostic code, 1.16 (95% CI = 1.13 to 1.18). Models accounted for between 2.2% and 3.9% of the variation in treatment duration. Patient demographic characteristics account for relatively little variation in the duration of new antidepressant treatment, though treatment was shorter in younger patients and those with greater socioeconomic deprivation. There is variation in treatment duration between practices and according to whether patients have a depression diagnosis coded in their records.

COPD exacerbations in general practice: variability in oral prednisolone courses.

BackgroundThe use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity.MethodsCross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands.ResultsThe response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity.ConclusionUnder normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.

Reductions in Postdischarge Suicide After Deinstitutionalization and Decentralization: A Nationwide Register Study in Finland

Reductions in Postdischarge Suicide After Deinstitutionalization and Decentralization: A Nationwide Register Study in Finland

Disability management of low back injuries by employer‐retained physicians: Ratings and costs

Background Medico-legal models of disability determination for low back pain lack empirical support. Besides diagnostic and functional parameters, social and situational factors may influence impairment/disability ratings and costs. Methods Archival data from employer-retained occupational medicine physician files and public court records were examined for 184 Workers' Compensation claimants with low back injuries. Regression was used to predict ratings, costs, and settlement duration from medical, functional, social, and situational variables. Results Diagnosis, surgery, pain, rating year, and clinic predicted impairment ratings from employer-retained physicians. The clinic effect partially reflected claimant ethnicity. Diagnosis, surgery, tests ordered, legal representation, and impairment rating predicted disability ratings at the administrative law judge level. Diagnosis, tests, and impairment rating predicted costs. For musculoskeletal diagnoses, settlement duration was related negatively to treatment duration and positively to costs. Conclusions Social and situational parameters influence disability management among employer-retained physicians, while functional variables have little impact. For musculoskeletal low back pain, increased disability and cost may result from variation in treatment duration. Am. J. Ind. Med. 38:529–538, 2000. © 2000 Wiley-Liss, Inc.

Effectiveness and duration of two-arch fixed appliance treatment

Abstract The aims of this study were to determine the effectiveness and duration of single-phase two-arch fixed appliance treatment and to evaluate factors that may influence these two variables. Data were collected from 177 consecutively completed cases at the Orthodontic Department, Government Dental Clinic, Singapore, during a three-month period. Pre-treatment and post-treatment models were assessed using the Peer Assessment Rating (PAR) index. The result showed that two-arch fixed appliance treatment reduced the malocclusions on average by 77.80 per cent over a period of 25 months. Multiple regression techniques revealed that 22 per cent of the variability in treatment effectiveness could be explained by the pre-treatment PAR score, the age at the start of treatment, the frequency of office visits and whether or not the treatment involved extractions. The variation in treatment duration was due to the frequency of office visits, the pre-treatment PAR score and whether or not the treatment involved extractions or headgear.

Disability management of low back injuries by employer-retained physicians: ratings and costs.

Medico-legal models of disability determination for low back pain lack empirical support. Besides diagnostic and functional parameters, social and situational factors may influence impairment/disability ratings and costs. Archival data from employer-retained occupational medicine physician files and public court records were examined for 184 Workers' Compensation claimants with low back injuries. Regression was used to predict ratings, costs, and settlement duration from medical, functional, social, and situational variables. Diagnosis, surgery, pain, rating year, and clinic predicted impairment ratings from employer-retained physicians. The clinic effect partially reflected claimant ethnicity. Diagnosis, surgery, tests ordered, legal representation, and impairment rating predicted disability ratings at the administrative law judge level. Diagnosis, tests, and impairment rating predicted costs. For musculoskeletal diagnoses, settlement duration was related negatively to treatment duration and positively to costs. Social and situational parameters influence disability management among employer-retained physicians, while functional variables have little impact. For musculoskeletal low back pain, increased disability and cost may result from variation in treatment duration.

An evaluation of factors affecting duration of orthodontic treatment

One of the first questions asked by new orthodontic patients is: How long will I need to wear my braces? A multitude of factors have the potential to influence the answer to this question. The purpose of this retrospective study was to identify some of the primary factors that influence orthodontic treatment duration. Few studies have attempted to evaluate these factors. Data were gathered from 140 consecutively completed, comprehensive treatment patient records in five orthodontic offices. Thirty-one variables related to patient characteristics, diagnostic factors, modality of treatment, and patient cooperation were evaluated. Average treatment time was 28.6 months with a range of 23.4 to 33.4 months among the five offices. Nearly half (46.9%) of the variation in treatment duration was explained by a five-step multiple regression analysis. Included in the regression equation were the number of missed appointments, the number of replaced brackets and bands, the number of treatment phases, the number of negative chart entries regarding oral hygiene, and the prescription of headgear wear during treatment. An additional 6.7% of the variance was explained by variation among the five offices. Six of the 31 variables examined made a statistically significant (α = .01) contribution to the explanation of variation in treatment time. The quality of the finished cases and the appropriateness of the original diagnosis and treatment plan were not evaluated. Developing an objective assessment to evaluate these areas may be important for increasing our understanding of treatment time variation. (Am J Orthod Dentofacial Orthop 1999;115:439-47)

A survey Of manual hyperinflation in Australian hospitals

A telephone survey was conducted to examine the use of manual hyperinflation (MHI) by physiotherapists in intensive care units (ICUs) in 32 Australian teaching hospitals. A 100 per cent response rate was obtained from senior ICU physiotherapists. Results showed that 91 per cent of respondents used manual hyperinflation as a physiotherapy treatment technique. There was strong agreement on the components of the technique, preferred treatment position, contraindications and perceived benefits but considerable variation in duration of treatment, number of breaths per set and circuits used. Fewer than 55 per cent stated that a maximum airways pressure of 40 cm H2O or less was used with MHI and only 31 per cent monitored airways pressure. These results are compared with previously published surveys.

The duration of orthodontic treatment

Characteristics of the patient, the treatment plan, and the practitioner's office were examined to evaluate causes for variation in the duration of orthodontic treatment. From six offices 118 patients were evaluated. All patients were treated in a single phase with fixed appliances. Appliances were worn for an average of 23.1 months. The mean duration for offices ranged from 19.4 to 27.9 months. Thirty-eight percent of the patients had extractions, and 32% wore headgear. Fifty percent of the variation in treatment duration among patients was explained by a five-step multiple regression equation. The variables entering this equation were (1) number of extracted premolars, (2) number of broken appointments, (3) pretreatment mandibular plane angle, (4) pretreatment ANB angle, and (5) pretreatment Salzmann Index. Observations within each office suggested that the time spent by individual clinicians in detailed finishing, which would not be detected by measures such as the Salzmann Index, was an important source of unexplained variation in treatment duration.