Retrospective comparison of filgrastim plus plerixafor to other regimens for remobilization after primary mobilization failure: clinical and economic outcomes

We performed a retrospective analysis to evaluate clinical and economic outcomes in patients receiving remobilization therapy after primary mobilization failure. Our primary endpoint was to compare filgrastim plus plerixafor to other regimens in their ability to collect a target cell dose of at least 2 million CD34+ cells/kg (cumulative). Of 96 consecutive patients who failed their primary mobilization therapy and in whom a second mobilization was attempted, remobilization consisted of filgrastim plus plerixafor (n = 38), filgrastim with or without sargramostim (n = 43), or chemotherapy plus filgrastim (n = 15), 84% of filgrastim/plerixafor patients were able to collect at least 2 million CD34+ cells/kg from both mobilizations, compared to 60% of patients mobilized with chemotherapy/filgrastim and 79% of the filgrastim ± sargramostim patients (P = 0.17). However, when combined with cells collected from the first mobilization, 53% of filgrastim/plerixafor patients reached the target of 2 million CD34+ cells in one apheresis, compared to 20% of those receiving chemotherapy/filgrastim and 28% of those receiving filgrastim ± sargramostim (P = 0.02). Resource utilization, mobilization drug costs, clinical care costs, and total costs were significantly different. We conclude that while filgrastim/plerixafor is the most efficient remobilization strategy, those clinical benefits may not translate into lower cost, especially when multiple days of plerixafor administration are required.     

Is Laparoscopic Appendectomy an Effective Procedure ?

Aim: To compare the results of open and laparoscopic appendectomy and to determine if the laparoscopic approach might be more effective for some subgroups of patients.

Material and methods: We retrospectively analysed the computerised data of 326 consecutive adult patients operated on for suspected appendicitis between 2001 and 2005. The series consisted of 166 men and 160 women with a mean age of 32 ± 16 years and a mean Body Mass Index (BMI) of 24 ± 4. There were 265 ASA I, 46 ASA II and 5 ASA III patients. According to the surgeon’s preference, 176 patients had an open appendectomy (OA) and 150 a laparoscopic appendectomy (LA).

Results: The mean operative time and hospital stay were equivalent in the two groups: respectively 49 ± 19 min. and 4.1 ± 2.5 days in OA and 50 ± 16 min. and 3.5 ± 1.8 days in LA. However, subgroup analysis revealed that overweight (BMI > 25) patients (n=102) and patients with ectopic appendices (n=86) had an obvious benefit from LA. In cases of OA, operative time and hospital stay were longer in overweight patients than in normal weight patients: respectively 63 ± 20 min. and 5.3 ± 2.9 days versus 44 ± 16 min. (p < 0.01) and 3.7 ± 2.2 days (p < 0.01). On the contrary, no difference was observed in the lA group. Operative time and hospital stay were also longer in patients with ectopic appendices submitted to OA than in patients with an appendix in the normal position: respectively 60 ± 18 min. and 4.7 ± 2.7 days versus 45 ± 18 min. (p < 0.01) and 3.9 ± 2.4 days (p < 0.01). Again, such a difference was not observed in cases of LA. We noted no mortality, but 24 patients (7%) developed an abdominal complication: 18 wound infections and 6 intra-abdominal abscesses. Wound infections were more common in the OA than in the LA group: 7.3% (13/176) versus 3.3% (5/150) (p = 0.1). In the LA group, 4 wound infections were observed in our early experience, at a time where no endoscopic bag was used for the removal of the appendix. The rate of intra-abdominal abscesses was similar: 1.7% (3/176) in the OA group and 2% (3/150) in the LA group.

Conclusions: LA is an effective procedure with a reduced risk of developing wound infection. The laparoscopic approach is particularly effective for overweight patients and/or patients with ectopic appendices as far as shortening the operative time and hospital stay are concerned.     

Prevalence, awareness, treatment, and control of hypertension among Canadian adults with diabetes, 2007 to 2009

Background

Prior national surveys suggested that treatment and control of hypertension were poor in individuals with diabetes. Using measured blood pressures, we estimated prevalence, awareness, treatment, and control of hypertension between 2007 and 2009 among Canadians with diabetes and sought to determine whether a treatment gap still exists for individuals with diabetes.

Methods

Using data from cycle 1 of the Canadian Health Measures Survey, estimates of hypertension prevalence, awareness, treatment, and control were described and compared between individuals with and without self-reported diabetes.

Results

Three-quarters of individuals reporting diabetes also had hypertension; of these, 89% (95% confidence interval [CI], 80%-98%) were aware, 88% (95% CI, 81%-94%) were treated, and 56% (95% CI, 45%-66%) were controlled to < 130/80 mm Hg. Among those treated with pharmacotherapy, 39% (95% CI, 31%-48%) were using monotherapy, 29% (95% CI, 18%-40%) were taking 2 medications, and 31% (95% CI, 22%-39%) were taking 3 or more medications; control to < 130/80 mm Hg was achieved by 63% (95% CI, 53%-74%). Among those treated, individuals with diabetes were significantly less likely to be treated to their recommended target (< 130/80 mm Hg) compared with individuals without diabetes (< 140/90 mm Hg; odds ratio_adjusted 0.3; 95% CI, 0.2-0.6).

Conclusions

Hypertension treatment and control among people with diabetes have improved in Canada during the past 2 decades. Nonetheless, nearly half of people with diabetes are above the treatment target. Health care professionals should continue to increase their efforts in supporting patients with diabetes in achieving blood pressure control, with emphasis on lifestyle management and pharmacotherapy.     

Insulin and its analogues and their affinities for the IGF1 receptor

Insulin analogues have been developed in an attempt to achieve a more physiological replacement of insulin and thereby a better glycaemic control. However, structural modification of the insulin molecule may result in altered binding affinities and activities to the IGF1 receptor (IGF1R). As a consequence, insulin analogues may theoretically have an increased mitogenic action compared to human insulin. In view of the lifelong exposure and large patient populations involved, insulin analogues with an increased mitogenic effect in comparison to human insulin may potentially constitute a major health problem, since these analogues may possibly induce the growth of pre-existing neoplasms. This hypothesis has been evaluated extensively in vitro and also in vivo by using animal models. In vitro, all at present commercially available insulin analogues have lower affinities for the insulin receptor (IR). Although it has been suggested that especially insulin analogues with an increased affinity for the IGF1R (such as insulin glargine) are more mitogenic when tested in vitro in cells expressing a high proportion of IGF1R, the question remains whether this has any clinical consequences. At present, there are several uncertainties which make it very difficult to answer this question decisively. In addition, recent data suggest that insulin (or insulin analogues)-mediated stimulation of IRs may play a key role in the progression of human cancer. More detailed information is required to elucidate the exact mechanisms as to how insulin analogues may activate the IR and IGF1R and how this activation may be linked to mitogenesis.     

Reported thresholds of self-motion perception are influenced by testing paradigm

Journal of Neurology - Different testing paradigms have been proposed to investigate perceptual self-motion thresholds. They can differ regarding the amount of possible motions that patients have...     

Determining clinical practice of expert physiotherapy for patients undergoing lumbar spinal fusion: a cross-sectional survey study

Purpose

To determine the content of current Dutch expert hospital physiotherapy practice for patients undergoing lumbar spinal fusion (LSF), to gain insight into expert-based clinical practice.

Methods

At each hospital where LSF is performed, one expert physiotherapist received an e-mailed questionnaire, about pre- and postoperative physiotherapy and discharge after LSF. The level of uniformity in goals and interventions was graded on a scale from no uniformity (50–60 %) to very strong uniformity (91–100 %).

Results

LSF was performed at 34 of the 67 contacted hospitals. From those 34 hospitals, 28 (82 %) expert physiotherapists completed the survey. Twenty-one percent of the respondents saw patients preoperatively, generally to provide information. Stated postoperative goals and administered interventions focused mainly on performing transfers safely and keeping the patient informed. Outcome measures were scarcely used. There was no uniformity regarding advice on the activities of daily living.

Conclusion

Dutch perioperative expert physiotherapy for patients undergoing LSF is variable and lacks structural outcome assessment. Studies evaluating the effectiveness of best-practice physiotherapy are warranted.