The role of salvage reirradiation for malignant gliomas that progress on bevacizumab

Bevacizumab and irinotecan are effective against recurrent malignant gliomas. However, at subsequent progression, patients rarely respond to a second bevacizumab-containing chemotherapeutic regimen. Salvage re-irradiation with bevacizumab for recurrent but bevacizumab naive malignant gliomas showed encouraging results. We performed a retrospective review of the medical records of 23 patients treated with either fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS) after progression on an initial bevacizumab regimen. Patients were treated after re-irradiation with bevacizumab but combined with a different chemotherapy. We then compared them to another 23 patients who progressed on an initial bevacizumab + chemotherapy regimen. These patients did not receive re-irradiation but bevacizumab was continued combined with a different chemotherapy. Patients treated with FSRT/SRS/bevacizumab had a longer median progression-free period (2.6 vs. 1. 7 months, P = 0.009), longer median post FSRT/SRS treatment survival (7.2 vs. 3.3 months, P = 0.03) and higher radiographic response rate (22 vs. 0%, P = 0.049). FSRT or SRS followed by bevacizumab + chemotherapy may have a role for patients who progress on bevacizumab.     

Comparative study of final visual outcome between open- and closed-globe injuries following surgical treatment of traumatic cataract

Objective  

The objective of this work is to compare final visual outcomes in cases of surgically treated traumatic cataract between open-globe and closed-globe groups, as classified by the Birmingham Eye Trauma Terminology system.     

Management of steroid sensitive nephrotic syndrome: revised guidelines

JUSTIFICATION: In 2001, the Indian Pediatric Nephrology Group formulated guidelines for management of patients with steroid sensitive nephrotic syndrome. In view of emerging scientific evidence, it was felt necessary to review the existing recommendations. PROCESS: Following a preliminary meeting in March 2007, a draft statement was prepared and circulated among pediatric nephrologists in the country to arrive at a consensus on the evaluation and management of these patients. OBJECTIVES: To revise and formulate recommendations for management of steroid sensitive nephrotic syndrome. RECOMMENDATIONS: The need for adequate cortico-steroid therapy at the initial episode is emphasized. Guidelines regarding the initial evaluation, indications for renal biopsy and referral to a pediatric nephrologist are updated. It is proposed that patients with frequently relapsing nephrotic syndrome should, at the first instance, be treated with long-term, alternate-day prednisolone. The indications for use of alternative immunosuppressive agents, including levamisole, cyclophosphamide, mycophenolate mofetil and cyclosporin are outlined. The principles of dietary therapy, management of edema, and prevention and management of complications related to nephrotic syndrome are described. These guidelines, formulated on basis of current best practice, are aimed to familiarize physicians regarding management of children with steroid sensitive nephrotic syndrome.     

Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline

Clinical practice guidelines (CPG) have been shown to decrease practice variation, reduce resource use, and improve patient outcomes. The purpose of this study was to audit compliance of a pediatric complicated appendicitis CPG to identify areas for continued improvement. A comprehensive complicated appendicitis CPG was implemented in a children’s hospital system. Outcomes were compared for 48 months pre- (01/2012 to 12/2015) and 28 months post-implementation (01/2016 to 04/2018). A detailed compliance audit was nested within the post-implementation period in 60 consecutive patients from 11/2017 to 03/2018. Feedback was provided to care providers throughout the audit. Overall, 2370 children with complicated appendicitis were identified (1366 pre-CPG and 1004 post-CPG). The CPG resulted in decrease in mean length of stay from 5.3 days to 4.5 days (p?=?0.751), postoperative returns to the system (13.0% to 10.1%, p?=?0.030), and readmissions (5.3% to 4.3%, p?=?0.237). Central line use decreased from 11.2% to 5.5% (p?<?0.001) and antibiotic selection improved from 47.0% to 84.1% (p?<?0.001). On audit, only 15% (9/60) had full CPG compliance and 49% (29/60) received recommended antibiotic durations. Compliance increased from 7% to 23% with audit-derived feedback. After stratifying by appendicitis severity, audits resulted in improved antibiotic duration compliance for patients with severe appendicitis (38.1% to 66.7%, p?=?0.07) and postoperative ambulation for patients with lower grade disease (37.5% to 83.3%, p?=?0.06). Audit cycles on a complicated appendicitis CPG and feedback to providers improved CPG compliance and more granular outcomes of interest.