Enzalutamide After Docetaxel and Abiraterone Therapy in Metastatic Castration-Resistant Prostate Cancer

Introduction

Enzalutamide is a novel antiandrogen which is approved for the treatment of metastatic, castration-resistant prostate cancer (mCRPC) after taxane-based chemotherapy. The efficacy of enzalutamide after the sequence docetaxel and abiraterone is not proven.

Methods

Thirty-five mCRPC patients in the German compassionate use program, who received enzalutamide after progression with taxane-based chemotherapy and abiraterone were prospectively evaluated. The endpoints of the study were overall survival, radiologic progression-free survival and safety.

Results

The median treatment duration on enzalutamide was 2.8 months. The median overall survival was 7.5 months [95% confidence interval (CI) 4.7–10.3] while median progression-free survival assessed by imaging was 3.1 months (95% CI 1.4–4.8). The most common toxicities of all grades were anemia and weight loss.

Conclusion

Although the results are limited by a small patient number, the consecutive use of enzalutamide and abiraterone after taxane-based chemotherapy shows a modest clinical activity. Thus, sequence therapy alternating between chemotherapy and antihormonal drugs might be a more promising approach in mCRPC treatment.     

Characteristics and prognosis of sudden cardiac death in Greater Paris

Purpose

Sudden cardiac death (SCD) is a major public health concern, but data regarding epidemiology of this disease in Western European countries are outdated. This study reports the first results from a large registry of SCD.

Methods

A population-based registry was established in May 2011 using multiple sources to collect every case of SCD in Paris and its suburbs, covering a population of 6.6 million. Utstein variables were recorded. Pre-hospital and in-hospital data were considered, and the main outcome was survival at hospital discharge. Neurologic status at discharge was established as well.

Results

Of the 6,165 cases of SCD recorded over 2 years, 3,816 had a resuscitation attempt and represent the study population. Most patients were male (69 %), the SCD occurred at home (72 %) with bystanders in 80 % of cases, and cardiopulmonary resuscitation (CPR) was performed in 45 % of cases. Initial rhythm was shockable in 26 % of cases. A total of 1,332 patients (35 %) were admitted alive to hospital. Among hospitalized patients, 58 % had a coronary angiogram, and the same proportion had therapeutic hypothermia. Finally, 279 patients (7.5 %) were discharged alive, of whom 96 % had a favorable neurological outcome. In multivariate analysis, bystander CPR (OR 2.1, 95 % CI 1.5–3.1) and initial shockable rhythm (OR 11.5, 95 % CI 7.6–17.3) were positively associated with survival at hospital discharge, whereas age (OR 0.97 per year, 95 % CI 0.96–0.98), longer response time (OR 0.93 per minute, 95 % CI 0.89–0.97), occurrence at home (OR 0.4, 95 % CI 0.3–0.6), and epinephrine dose greater than 3 mg (OR 0.05, 95 % CI 0.03–0.08) were inversely associated with survival.

Conclusion

Despite being conducted in the therapeutic hypothermia and early coronary angiogram era, hospital discharge survival rate of resuscitated SCD remains poor. The current registry suggests ways to improve pre-hospital and in-hospital care of these patients.     

A retrospective study to evaluate the time burden associated with outpatient red blood transfusions indicated for anemia due to concomitantly administered chemotherapy in cancer patients

Purpose

Anemia in cancer patients can be treated with red blood cell (RBC) transfusions. The patient burden associated with a treatment in terms of total time spent is an important factor to consider when measuring the benefits and challenges of a therapy. This study estimates the time-related patient burden associated with outpatient RBC transfusion.

Methods

A retrospective chart review of outpatient cancer patients receiving a RBC transfusion was conducted at 10 US centers. RBC transfusion time was measured as time elapsed from pre- to post-transfusion vital sign assessment and from transfusion start to stop time. Elapsed time from hemoglobin level testing and blood draw for cross-match to transfusion, estimated travel time and distance, and clinical and demographic data were also collected.

Results

Data from 110 patients (48.2 % male; mean age 64?±?12 years) showed that the mean elapsed time between pre- and post-vital sign assessment was 4.2 h (95 % confidence interval (CI), 3.64–4.81) including 3.6 h (95 % CI, 3.0–4.1) on average to receive the actual RBC transfusion treatment. Hemoglobin level testing (mean Hg level, 8.33 g/dL?±?0.67) and blood drawn for cross-match were completed in an average of 31.2 h (95 % CI, 17.0–45.5) and 18.2 h (95 % CI, 12.1–24.2) prior to transfusion, respectively. Patient one-way travel time averaged 30.0 min (95 % CI, 25.9–34.3).

Conclusions

In the US, CIA patients experience an important time burden when being treated with RBC transfusion in addition to the burden already added by chemotherapy.     

Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data

Background

Neurologic complications in neonates supported with extracorporeal membrane oxygenation (ECMO) are common and diminish their quality of life and survival. An understanding of factors associated with neurologic complications in neonatal ECMO is lacking. The goals of this study were to describe the epidemiology and factors associated with neurologic complications in neonatal ECMO.

Patients and methods

Retrospective cohort study of neonates (age ≤30 days) supported with ECMO using data reported to the Extracorporeal Life Support Organization during 2005–2010.

Results

Of 7,190 neonates supported with ECMO, 1,412 (20 %) had neurologic complications. Birth weight <3 kg [odds ratio (OR): 1.3; 95 % confidence intervals (CI): 1.1–1.5], gestational age (<34 weeks; OR 1.5, 95 % CI 1.1–2.0 and 34–36 weeks: OR 1.4, 95 % CI 1.1–1.7), need for cardiopulmonary resuscitation prior to ECMO (OR 1.7, 95 % CI 1.5–2.0), pre-ECMO blood pH ≤ 7.11 (OR 1.7, 95 % CI 1.4–2.1), pre-ECMO bicarbonate use (OR 1.3, 95 % CI 1.2–1.5), prior ECMO exposure (OR 2.4, 95 % CI 1.6–2.6), and use of veno-arterial ECMO (OR 1.7, 95 % CI 1.4–2.0) increased neurologic complications. Mortality was higher in patients with neurologic complications compared to those without (62 % vs. 36 %; p < 0.001).

Conclusions

Neurologic complications are common in neonatal ECMO and are associated with increased mortality. Patient factors, pre-ECMO severity of illness, and use of veno-arterial ECMO are associated with increased neurologic complications. Patient selection, early ECMO deployment, and refining ECMO management strategies for vulnerable populations could be targeted as areas for improvement in neonatal ECMO.     

Long-term mortality in patients with chronic obstructive pulmonary disease following extracorporeal membrane oxygenation for cardiac assist after cardiovascular surgery

Purpose

Information on predisposing risk factors influencing long-term survival after extracorporeal membrane oxygenation (ECMO) support remains scarce. In critically ill patients chronic obstructive pulmonary disease (COPD) is an independent risk factor for mortality and morbidity. We assessed the influence of COPD on cardiovascular and all-cause mortality in patients undergoing ECMO therapy.

Methods

We prospectively included 191 patients undergoing veno-arterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center into our registry.

Results

The median follow-up time was 51 months (IQR 34–71 months) corresponding to 4,197 overall months of follow-up. A total of 125 patients (65 %) died; 88 % of deaths were due to cardiovascular causes. Long-term survival was decreased in patients with COPD after 1 year (23 % vs. 44 %) and after 6 years (14 % vs. 35 %) compared to patients without COPD. COPD was independently associated with all-cause mortality with a hazard ratio of 4.22 (95 % CI 1.04–17.11, p = 0.04) and cardiovascular mortality with a hazard ratio of 5.87 (95 % CI 1.41–24.47, p = 0.02).

Conclusions

We identified COPD as a strong and independent predictor of long-term all-cause mortality and cardiovascular mortality in patients undergoing ECMO therapy following cardiovascular surgery. The current study presents valuable information for a comprehensive decision-making process prior to ECMO implantation and helps to identify high-risk patients that may benefit from intensified treatment of co-morbidities and close check-ups after hospital discharge.     

Long-term follow-up for cardiovascular disease after chemotherapy and/or radiotherapy for breast cancer in an unselected population

Purpose

Whereas earlier research focused on specific patient groups, this study assessed the risk of cardiovascular disease (CVD) in an unselected population curatively treated for breast cancer (BC), compared with an age-matched random sample of controls.

Methods

Risks were determined in BC survivors and controls. CVD was divided into three categories: congestive heart failure, vascular cardiac diseases, and “other” cardiac diseases. Hazard ratios (HRs) and 95 % confidence intervals (95 % CI) adjusted for age, CVD, and CVD risk factors at baseline were determined by Cox regression analyses.

Results

All 561 survivors of BC experienced surgery of whom 229 received (neo)adjuvant radiotherapy, 145 received chemotherapy (with or without radiotherapy), and 187 received no adjuvant therapy. During follow-up (median 9; range 5–57 years), CVD occurred in 176/561 (31 %) survivors and in 398/1,635 (24 %) controls. After radiotherapy, no increased risks of congestive heart failure (HR 0.5; 95 % CI 0.2–1.8), vascular cardiac diseases (HR 1.1; 95 % CI 0.7–1.7), or other cardiac diseases (HR 1.3; 95 % CI 0.8–2.3) were found compared with controls. Similar results were found after chemotherapy for congestive heart failure (HR 1.8; 95 % CI 0.6–5.8), vascular cardiac diseases (HR 1.1; 95 % CI 0.5–2.3), and other cardiac diseases (HR 1.2; 95 % CI 0.3–5.5).

Conclusions

In an unselected population of BC survivors, no significant increased risk of CVD after radiotherapy and/or chemotherapy was found compared with controls. However, the HRs after chemotherapy were in-line with previous studies. Future studies should include more detailed information on treatment and more specific outcome measures.     

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

Background

Intensive care unit (ICU) admission of patients with lung cancer remains debated because of the poor short-term prognosis. However, ICU admission of such patients should also be assessed on the possibility to administer specific anticancer treatment and the long-term outcome thereafter.

Objectives

To identify predictive factors of hospital and 6-month mortality in critically ill lung-cancer patients.

Design and setting

Retrospective study conducted in the ICU of a university hospital.

Patients

One hundred five consecutive lung-cancer patients included between 1 January 1997 and 31 December 2006.

Interventions

None.

Results

Of the 105 patients (mean age 64.8 years), 87 (83%) had a non-small cell lung cancer (NSCLC). Extensive disease was diagnosed in 85 patients (83%) (NSCLC stages IIIB and IV or disseminated small cell lung cancer). The main reasons for ICU admission were acute respiratory failure (59%) and/or hemoptysis (45%). Forty-three patients (41%) needed mechanical ventilation (MV). The ICU, hospital and 6-month mortality rates were 43, 54 and 73%, respectively. A performance status (PS) ≥2 [odds ratio OR = 3.6 (95% confidence interval CI (1.5–8.7)] and acute respiratory failure [OR = 3.5 (95% CI (1.5–8.4)] predicted hospital mortality. In a multivariate Cox model, the cancer progression [hazard ratio HR = 6.1 (95% CI 2.2–17)] and the need for MV [HR = 3.6 (95% CI 1.35–9.4)] were independently associated with 6-month mortality. Two-thirds of the ICU survivors were able to receive anticancer treatment.

Conclusions

ICU admission should be considered in selected patients with lung cancer (PS <2, no cancer disease progression).     

Factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study

Purpose

To analyze prognostic factors associated with in-hospital cardiac arrest (CA) in children.

Methods

A prospective, multicenter, multinational, observational study was performed on pediatric in-hospital CA in 12 countries and included 502 children between 1 month and 18 years. The primary endpoint was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality.

Results

Return of spontaneous circulation was achieved in 69.5 % of patients; 39.2 % survived to hospital discharge and 88.9 % of survivors had good neurological outcome. The pre-arrest factors related to mortality were lower Human Development Index [odds ratio (OR) 2.32, 95 % confidence interval (CI) 1.28–4.21], oncohematologic disease (OR 3.33, 95 % CI 1.60–6.98), and treatment with inotropic drugs at the time of CA (OR 2.35, 95 % CI 1.55–3.56). CA and resuscitation factors related to mortality were CA due to neurological disease (OR 5.19, 95 % CI 1.49–18.73) and duration of cardiopulmonary resuscitation greater than 10 min (OR 4.00, 95 % CI 1.49–18.73). Factors related to survival were CA occurring in the pediatric intensive care unit (PICU) (OR 0.38, 95 % CI 0.16–0.86) and shockable rhythm (OR 0.26, 95 % CI 0.09–0.73).

Conclusions

In-hospital CA in children has a low survival but most of the survivors have a good neurological outcome. Some prognostic risk factors cannot be modified, making it important to focus efforts on improving hospital organization to care for children at risk of CA in the PICU and, in particular, in other hospital areas.     

Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective,multicenter, observational study

Purpose

Frailty is a recent concept used for evaluating elderly individuals. Our study determined the prevalence of frailty in intensive care unit (ICU) patients and its impact on the rate of mortality.

Methods

A multicenter, prospective, observational study performed in four ICUs in France included 196 patients aged ≥65 years hospitalized for >24 h during a 6-month study period. Frailty was determined using the frailty phenotype (FP) and the clinical frailty score (CFS). The patients were separated as follows: FP score <3 or ≥3 and CFS <5 or ≥5.

Results

Frailty was observed in 41 and 23 % of patients on the basis of an FP score ≥3 and a CFS ≥5, respectively. At admission to the ICU, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores did not differ between the frail and nonfrail patients. In the multivariate analysis, the risk factors for ICU mortality were FP score ≥3 [hazard ratio (HR), 3.3; 95 % confidence interval (CI), 1.6–6.6; p < 0.001], male gender (HR, 2.4; 95 % CI, 1.1–5.3; p = 0.026), cardiac arrest before admission (HR, 2.8; 95 % CI, 1.1–7.4; p = 0.036), SAPS II score ≥46 (HR, 2.6; 95 % CI, 1.2–5.3; p = 0.011), and brain injury before admission (HR, 3.5; 95 % CI, 1.6–7.7; p = 0.002). The risk factors for 6-month mortality were a CFS ≥5 (HR, 2.4; 95 % CI, 1.49–3.87; p < 0.001) and a SOFA score ≥7 (HR, 2.2; 95 % CI, 1.35–3.64; p = 0.002). An increased CFS was associated with significant incremental hospital and 6-month mortalities.

Conclusions

Frailty is a frequent occurrence and is independently associated with increased ICU and 6-month mortalities. Notably, the CFS predicts outcomes more effectively than the commonly used ICU illness scores.     

Long-term survival in patients with different combinations of evidence-based medications after incident acute myocardial infarction: results from the MONICA/KORA Myocardial Infarction Registry

Background

Use of the four evidence-based medications [EBMs: antiplatelet agent, beta-blocker, statin and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB)] after acute myocardial infarction (AMI) has a clear impact on 1-year survival. Aim of this study was to evaluate the association between different EBM combinations at discharge and long-term survival after AMI.

Methods

From a German population-based AMI registry, 2,886 men and 958 women were included, aged 28–74 years, hospitalized with an incident AMI between 2000 and 2008. All data were collected by standardized interviews and chart review. All-cause mortality was assessed for all registered persons in 2010. Median follow-up time was 6.0 years (interquartile range 4.1 years). Survival analyses and multivariate Cox regression analysis were conducted.

Results

Of the 3,844 patients, 70.3 % were prescribed all four EBMs; 23.8 % received three, 4.6 % two, and 1.3 % were discharged with one or no EBM. Long-term survival was 71.7 % [95 % confidence interval (CI) 55.4–82.9 %], 64.7 % (95 % CI 59.2–69.6 %) and 60.2 % (95 % CI 51.9–67.5 %) in patients with four, three and <3 EBMs, respectively. Patients prescribed three or less EBMs without ACEI/ARB showed similar long-term survival to those receiving four EBMs. In Cox regression analysis after adjustment for confounding variables, the hazard ratio for long-term mortality in patients with four EBMs versus three or less EBMs was 0.63 (95 % CI 0.53–0.74).

Conclusions

Prescribing of a combination of all four EBMs appeared to improve clinical outcomes in AMI patients by significantly reducing long-term mortality. Hospital discharge is a critical time for optimal long-term management.     

Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis

Background

Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.

Objective

To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mmHg] compared with moderate hypoxemia (100 mmHg ≤ PaO₂/FiO₂ ≤ 300 mmHg).

Design

Systematic review and meta-analysis.

Data Sources

Electronic databases (to November 2009) and conference proceedings.

Methods

Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO₂/FiO₂ <100 mmHg. Meta-analyses used study-level random-effects models.

Results

Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO₂/FiO₂ <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO₂/FiO₂ ≥100 mmHg (RR 1.07, 95% CI 0.93–1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO₂/FiO₂ thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27–39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16–1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24–2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02–9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.

Conclusions

Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.     

Serious postoperative infections following resection of common solid tumors: outcomes, costs, and impact of hospital surgical volume

Purpose

Unlike infections related to chemotherapy-induced neutropenia, postoperative infections occurring in patients with solid malignancy remain largely understudied. Our aim is to evaluate the outcomes and the volume–outcomes relationship associated with postoperative infections following resection of common solid tumors.

Methods

We used Texas Discharge Data to study patients undergoing resection of cancer of the lung, esophagus, stomach, pancreas, colon, or rectum from 01/2002 to 11/2006. From their billing records, we identified ICD-9 codes indicating a diagnosis of serious postoperative infection (SPI), i.e., bacteremia/sepsis, pneumonia, and wound infection, occurring during surgical admission or leading to readmission within 30 days of surgery. Using regression-based techniques, we estimated the impact of SPI on mortality, resource utilization, and costs, as well as the relationship between hospital volume and SPI, after adjusting for confounders and data clustering.

Results

SPI occurred following 9.4 % of the 37,582 eligible tumor resections and was independently associated with nearly 12-fold increased odds of in-hospital mortality [95 % confidence interval (95 % CI), 7.2–19.5, P?<?0.001]. Patients with SPI required six additional hospital days (95 % CI, 5.9–6.2) at an incremental cost of $16,991 (95 % CI, $16,495–$17,497). Patients who underwent resection at high-volume hospitals had a 16 % decreased odds of developing SPI than those at low-volume hospitals (P?=?0.03).

Conclusions

Due to the substantial burden associated with SPI following common solid tumor resections, hospitals must identify more effective prophylactic measures to avert these potentially preventable infections. Additional volume–outcomes research is needed to identify infection prevention processes that can be transferred from high- to lower-volume providers.     

Incidence of infusion-site reactions associated with peripheral intravenous administration of fosaprepitant

Purpose

Fosaprepitant is known to cause infusion-site reactions. However, there is limited data regarding these reactions including the effect of peripheral intravenous administration or other potential factors on their incidence. This single-institution retrospective study was undertaken to investigate the incidence of infusion-site reactions with single-dose intravenous (IV) fosaprepitant when given through a peripheral line prior to administration of chemotherapy. Risk factors for the development of infusion-site reactions with fosaprepitant were also explored.

Methods

Medical records of patients with cancer receiving IV fosaprepitant through a peripheral line were reviewed. The primary objective of this study was to estimate the incidence of infusion-site reactions at our institution. Data collection included demographics, fosaprepitant infusion information, and grading of reactions.

Results

We found a 15 % incidence of infusion-site reactions among all peripherally administered doses of fosaprepitant. The 50 reactions occurred in 43 unique patients representing an incidence per patient of 28.7 % (43/150; 95 % confidence interval (CI) 21.6–36.6). Factors found to be associated with infusion-site reactions included age [odds ratio (OR) 0.97 (95 % CI 0.94–0.99)], location of IV line [OR forearm vs. hand 0.41 (95 % CI 0.20–0.85); OR antecubital fossa vs. hand 0.31 (95 % CI 0.11–0.87)], and simultaneous maintenance IV fluid rate ≥100 mL/h during fosaprepitant infusion [OR 0.19 (95 % CI 0.08–0.44)].

Conclusions

The incidence of infusion-site reactions with peripherally administered fosaprepitant as seen in this study is higher than that reported in the package insert. Risk factors for developing infusion-site reactions in our patient population include age, location of IV line, and simultaneous maintenance IV fluid rate of <100 mL/h.     

Glucocorticoid-induced diabetes mellitus in patients with lymphoma treated with CHOP chemotherapy

Purpose

Glucocorticoid-induced diabetes mellitus (GDM) is a major complication arising from corticosteroid administration, but there is lack of studies on GDM attributing to CHOP chemotherapy. We studied the incidence and risk factors for GDM development in patients with lymphoma during CHOP chemotherapy.

Methods

We analyzed 80 patients with lymphoma treated with a CHOP regimen with or without rituximab between 2004 and 2012 at the University of Tsukuba hospital. Patients with a known history of DM were excluded. Diagnosis of DM was performed according to the American Diabetes Association’s criteria.

Results

Among the 80 patients, 26 (32.5 %) developed GDM. We found that age ≥60 years, glycated hemoglobin (HbA1c) levels >6.1 %, body mass index (BMI) >30 kg/m², prednisolone administration prior to chemotherapy, history of hypertension or hypertension at admission, and the presence of metabolic syndrome were significant (p?≤?0.05) factors associated with GDM development by univariate analysis. Multivariate analysis revealed that age ≥60 years [p?<?0.05; hazard ratio (HR)?=?3.59; 95 % confidence interval (CI), 1.22–10.51], HbA1c levels >6.1 % (p?<?0.05; HR?=?9.35; 95%CI, 1.45–60.34), and BMI >30 kg/m² (p?=?0.052; HR?=?6.27; 95%CI, 0.98–40.00) were independently significant association factors.

Conclusion

The results suggest a guideline for plasma glucose monitoring during CHOP chemotherapy in patients with no history of DM.     

Racial disparities in the use of palliative therapy for ureteral obstruction among elderly patients with advanced prostate cancer

Objectives

Palliative issues are an important but understudied issue for patients with advanced cancer. Ureteral obstruction is a complication of advanced prostate cancer, usually relieved with placement of retrograde ureteral stent (RUS) or percutaneous nephrostomy (PCN) to palliate symptoms associated with obstructive uropathy and/or renal failure. We investigated predictors of receipt of RUS and PCN and their association with survival for older advanced prostate cancer patients.

Methods

Using the Surveillance, Epidemiology, and End Results–Medicare database, we identified patients aged 65 or older with stage IV (n?=?10,848) or recurrent (n?=?7,872) prostate cancer. We used multivariable analysis to compare those with ureteral obstruction treated with RUS or PCN to those not treated and to analyze the association between RUS, PCN, and survival.

Results

Sixteen percent (n?=?2,958) of the sample developed ureteral obstruction. Compared to no treatment, African Americans were more likely to undergo placement of PCN [odds ratio 1.48, 95 % confidence intervals (CI) 1.03–2.13] than Whites, but equally likely to receive a stent. Subjects of >80 years were less likely to undergo RUS (ages 80–84, 0.41, 95 % CI 0.27–0.63; ages ≥85, 0.30, 95 % CI 0.16–0.54) compared to patients 65–69 years. Subjects who received a PCN were 55 % more likely to die than those who were untreated. There was no difference in survival among those receiving RUS vs untreated. Nine percent of subjects received RUS or PCN within 30 days of dying.

Conclusions

This is the first population-based study to demonstrate a racial disparity in the palliative treatment of advanced prostate cancer. Reasons for disparate care need to be determined so that interventions may be developed.     

The duration of SIRS before organ failure is a significant prognostic factor of sepsis

Background

A growing elderly population along with advances in equipment and approaches for pre-hospital resuscitation necessitates up-to-date information when developing policies to improve elderly out-of-hospital cardiac arrest (OHCA) outcomes. We examined the effects of bystander type (family or non-family) intervention on 1-month outcomes of witnessed elderly OHCA patients.

Methods

Data from a total of 85,588 witnessed OHCA events in patients aged ≥65 years, which occurred from 2005 to 2008, were obtained from a nationwide population-based database. Patients were stratified into three age categories (65–74, 75–84, ≥85 years), and the effects of bystander type (family or non-family) on initial cardiac rhythm, rate of bystander cardiopulmonary resuscitation (CPR), and 1-month outcomes were assessed.

Results

The overall survival rate was 6.9% (65–74 years: 9.8%, 75–84 years: 6.9%, ≥85 years: 4.6%). Initial VF/VT was recorded in 11.1% of cases with a family bystander and 12.9% of cases with a non-family bystander. The rate of bystander CPR was constant across the age categories in patients with a family bystander and increased with advancing age categories in patients with a non-family bystander. Patients having a non-family bystander were associated with significantly higher 1-month rates of survival (OR: 1.26; 95% CI: 1.19–1.33) and favorable neurological status (OR: 1.47; 95% CI: 1.34–1.60).

Conclusions

Elderly patient OHCA events witnessed by a family bystander were associated with worse 1-month outcomes than those witnessed by a non-family bystander. Healthcare providers should consider targeting potential family bystanders for CPR education to increase the rate and quality of bystander CPR.     

Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team

Purpose

To prospectively evaluate the implementation of a rapid response team in the form of a medical emergency team (MET) with regard to cardiac arrests and hospital mortality.

Methods

Prospective before-and-after trial of implementation of a MET at the Karolinska University Hospital, Stockholm, Sweden. All adult patients, apart from cardiothoracic, admitted to the hospital were regarded as participants in the study. A control period of 5 years and 203,892 patients preceded the 2-year intervention period of 73,825 patients.

Main results

Number of MET calls was 9.3 per 1,000 hospital admissions. Cardiac arrests per 1,000 admissions decreased from 1.12 to 0.83, OR 0.74 (95% CI 0.55–0.98, p = 0.035). Adjusted for age, sex, hospital length of stay, acute/elective admission as well as co-morbidities, MET implementation was associated with a reduction in total hospital mortality by 10%, OR 0.90 (95% CI 0.84–0.97), p = 0.003. Hospital mortality was also reduced for medical patients by 12%, OR 0.88 (95% CI 0.81–0.96, p = 0.002) and for surgical patients not operated upon by 28%, OR 0.72 (95% CI 0.56–0.92, p = 0.008).

For patients fulfilling the MET criteria

Thirty-day mortality pre-MET was 25% versus 7.9% following MET compared with historical controls. Similarly, 180-day mortality was 37.5% versus 15.8%, respectively.

Conclusions

Implementing the MET team was associated with significant improvement in both cardiac arrest rate and overall adjusted hospital mortality. Significant reductions in hospital mortality for un-operated surgical patients as well as for medical patients were also seen. Thus, introduction of the MET seemed to improve outcome for hospitalized patients.     

De-escalation of antimicrobial treatment in neutropenic patients with severe sepsis: results from an observational study

Background

In severe sepsis, guidelines recommend de-escalating the empirical antimicrobial treatment as soon as the microbiological results are available. We aimed to determine the rate of de-escalation of the empirical antimicrobial treatment in neutropenic patients with severe sepsis. The characteristics of antimicrobial treatment associated with de-escalation and its impact on short- and long-term survival were also determined.

Methods

In the intensive care unit (ICU) of a cancer referral center, we prospectively collected observational data related to the antimicrobial management in neutropenic patients who developed severe sepsis and were admitted to ICU for at least 48 h. De-escalation of antimicrobial therapy consisted either of deleting one of the empirical antibiotics of a combined treatment, or, whenever possible, to use a betalactam antibiotic with a narrower spectrum of activity. Multivariate logistic regression was conducted to determine the factors associated with de-escalation, while a Cox proportional hazards model with a time-dependent covariate was fitted to assess the effect of de-escalation on 30-day survival. Finally 1-year survival after ICU discharge was compared across de-escalation groups.

Results

Cumulative incidence of de-escalation of the empirical antimicrobial treatment among the 101 patients of the cohort was 44 %, [95 % confidence interval (CI) 38–53 %], including 30 (68 %) patients with ongoing neutropenia. A microbiological documentation was available in 63 (63 %) patients. Factors associated with de-escalation were the adequation of the empirical antimicrobial treatment in ICU [OR = 10.8 (95 % CI 1.20–96)] for adequate documented treatment versus appropriate empirical treatment, the compliance with guidelines regarding the empirical choice of the anti-pseudomonal betalactam [OR = 10.8 (95 % CI 1.3–89.5)]. De-escalation did not significantly modify the hazard of death within the first 30 days [HR = 0.51 (95 % CI 0.20–1.33)], nor within 1 year after ICU discharge [HR = 1.06 (95 % CI 0.54–2.08)].

Conclusion

Our data suggest that, in ICU, de-escalation of the empirical antimicrobial treatment is frequently applied in neutropenic cancer patients with severe sepsis. No evidence of any prognostic impact of this de-escalation was found.     

Cardiopulmonary resuscitation among mechanically ventilated patients

Purpose

To evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation (CPR) in mechanically ventilated patients.

Methods

We analyzed Medicare data from 1994 to 2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated [defined by ICD-9 procedure code for intubation (96.04) or mechanical ventilation (96.7x) one or more days prior to procedure code for CPR (99.60 or 99.63)].

Results

We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4 % [95 % confidence interval (CI) 18.3–18.5 %]. Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1 % (95 % CI 9.8–10.4 %), compared to 19.2 % (95 % CI 19.1–19.3 %) in non-ventilated patients (p < 0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52 % lower odds of survival (OR 0.48, 95 % CI 0.46–0.49, p < 0.001). Median long-term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95 % CI 5.3–6.8 months), compared to 19.0 months (95 % CI 18.6–19.5 months) among the non-ventilated survivors (p < 0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1 % were alive at 1 year.

Conclusions

Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.