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Author(s):  
Hamid Farhangi ◽  
Ali Ghasemi ◽  
Mojgan Bahari ◽  
Zohreh Alirezaei ◽  
Akram Rabbani Javadi ◽  
...  

Background: Nausea and vomiting are among the most important side-effects associated with chemotherapy in children with cancer, affecting the quality of their lives. Clinical guidelines for selecting antiemetics are effective in reducing acute chemotherapy-induced nausea and vomiting (CINV). Materials and Methods: The present quasi-experimental study compared the effectiveness of the Pediatric Oncology Group of Ontario (POGO) CINV guideline with that of conventional arbitrary therapies for CINV in 82 children aged 6 months to 16 years old. Out of 177 cycles of chemotherapy, in 101 cycles patients were treated according to POGO-CINV Guideline; in the other 76 cycles, patients were treated with arbitrary types and doses of antiemetics. Then, vomiting in the first 24 hours after chemotherapy in both groups was measured and compared. Results: In this study, 82 patients hospitalized in the Hematology Department of Dr. Sheikh Children’s Hospital were enrolled, of whom 48 patients (58.7%) were boys and 34 (41.3%) were girls. The mean age of patients was 6.24±4.47 years (6 months to 16 years). The results of the current study showed that using a protocol for the prevention of vomiting based on the patient’s age and the type of chemotherapy is superior to conventional management of CINV. Findings showed that the frequency of nausea and vomiting in the protocol group was significantly reduced in comparison with the control group (p˂0.005). Moreover, a reduction in the frequency of nausea and vomiting was quite significant in the sub-categories of the protocol group who had received high-risk or moderate-risk emetogenic drugs (p˂0.005). Conclusion: The results of the current study showed that using the POGO guideline, which takes into account the patient’s age and the type of chemotherapy, is more effective than arbitrary management of CINV, particularly in children.


Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4572-4572
Author(s):  
Kendra Jones ◽  
Leila Mohassel ◽  
Raymund Cuevo

Abstract Introduction: High-dose methotrexate (HD-MTX) requires extensive monitoring and implementation of supportive care strategies to prevent associated toxicities. Although monitoring protocols for MTX vary across institutions, standardized supportive care measures can improve treatment outcomes. The purpose of this study was to evaluate the impact of a pharmacist-driven monitoring protocol on management of patients with delayed MTX elimination. Methods: This was a single-center, retrospective analysis that included hospitalized adult cancer patients receiving HD-MTX therapy (≥ 1 g/m 2). The study consisted of a pre-protocol group (August 2014 to July 2017) and a post-protocol group (August 2017 to August 2020). Patients were included in the analysis more than once if they had a repeat but separate hospital encounter. The primary outcome measure was to compare the rate of appropriate leucovorin dosage adjustments, defined by adherence to institution-specific HD-MTX monitoring guidelines, before and after protocol implementation (Table 1). Secondary outcomes included MTX concentrations at 24, 48, and 72 hours; time to MTX elimination; evidence of delayed MTX clearance; urine pH; length of stay; drug-drug interactions; and incidence of toxicities. Group comparisons for continuous data were made using Mann-Whitney U test and Chi-square or Fisher's exact test was used for categorical data. A p-value of < 0.05 was used to indicate significance. Results: Of 272 hospital encounters initially identified, 82 pre-protocol encounters and 59 post-protocol encounters were included in the analysis. Thirty-five percent of patient encounters in the pre-protocol group were excluded as a result of inappropriately timed methotrexate levels compared to only 9% in the post-protocol group, indicating improved MTX monitoring after protocol implementation. Baseline characteristics are summarized in Table 2. The most common malignancy was primary CNS lymphoma (53.8%) followed by non-Hodgkin lymphoma (28.8%). HD-MTX monotherapy was the most common regimen used in the pre-protocol group (57.1%) whereas combination therapy with rituximab +/- procarbazine was the most common regimen used in the post-protocol group (62.5%). Twenty-one encounters in the pre-protocol group and 22 encounters in the post-protocol group required leucovorin dose escalations at 24, 48, or 72 hours (Table 3). Following the implementation of the pharmacist-driven protocol, the rate of appropriate leucovorin dose adjustments increased significantly from 61.9% to 90.9% (p = 0.034). The median methotrexate concentration at 48 and 72 hours was higher in the post-protocol group when compared to the pre-protocol group. [0.22 µM/L vs.0.18 µM/L (p = 0.019) and 0.1 µM/L vs. 0.07 µM/L (p < 0.001), respectively]. Median time to methotrexate elimination was slightly longer in patients managed according to the MTX protocol [73 hours vs. 72.4 hours, p = 0.022] with higher rates of delayed clearance noted in these patients [18 (30.5%) vs. 16 (19.5%), p < 0.001]. There were no statistically significant differences in length of stay, urine pH, or drug-drug interactions between the two groups during methotrexate therapy (Table 4). However, a lower percentage of concomitant drug interactions with methotrexate were identified after protocol implementation, suggesting improved drug interaction screening [29 (49.2%) vs. 53 (64.9%), p = 0.857]. Rates of toxicities are shown in Table 5. The post-protocol group experienced a higher incidence of any-grade hyperbilirubinemia [20 (33.9%) vs. 18 (22%), p = 0.019], encephalopathy [10 (17%) vs. 5 (6.1%), p = 0.043], and grade ≥ 3 neutropenia [4 (6.8%) vs. 4 (4.9%), p = 0.009]. These differences in toxicity rates may in part be due to more frequent use of multi-agent chemotherapy in the post-protocol group and greater number of MTX cycles administered to these patients. The incidence of nephrotoxicity was similar in both groups (6 (7.3%) vs. 5 (8.5%), p= 0.493) and in line with previous reports. Conclusion:The implementation of a pharmacist-driven HD-MTX monitoring protocol improved optimal timing of MTX serum concentrations, resulted in a statistically significant improvement in the rate of appropriate leucovorin dose escalations, and led to enhanced detection of drug interactions. These findings demonstrate the important role pharmacists can play in dosing and monitoring high-risk regimens. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.


2021 ◽  
Author(s):  
Jun Wang ◽  
Jing Zhang ◽  
Nan Zhao ◽  
Yuan Ma ◽  
Xiyi Wang ◽  
...  

Abstract Background: Studies in oocytes have suggested increased aneuploidy rates after ovulation induction in mammals and humans. Conversely, some studies have shown that ovarian stimulation does not significantly increase the embryo aneuploidy rate in humans compared with an unstimulated cycle. In addition, the potential effect of the gonadotropin-releasing hormone (GnRH) antagonist (GnRH-ant) protocol and GnRH agonist (GnRH-a) long protocol on embryo aneuploidy remains unknown.Methods: This is the retrospective cohort study from university-affiliated fertility center. In total, 578 early miscarriage patients who conceived through IVF/intracytoplasmic sperm injection (ICSI) after receiving the gonadotropin-releasing hormone (GnRH) antagonist (GnRH-ant) protocol or the GnRH agonist (GnRH-a) long protocol were analyzed to compare the aneuploidy rates in early aborted tissues. In addition, a total of 466 preimplantation genetic testing for aneuploidy (PGT-A) cycles undergoing GnRH-ant protocol or GnRH-a long protocol were also analyzed to compare the aneuploidy rates in embryo.Results: For early miscarriage patients who conceived through IVF/ICSI, compared to the GnRH-a long protocol group, the GnRH-ant protocol group had a significantly higher rate of aneuploidy in early aborted tissues (48.70% vs. 64.52%), and increased aneuploidy was associated with a significantly higher incidence of trisomy 13, 18, and 21 (p<0.01). Regarding PGT-A cycles, compared to the GnRH-a long protocol group, the rate of embryo aneuploidy was also significantly higher in the GnRH-ant protocol group (48.01% vs. 58%). After stratification and multiple linear regression, the GnRH-ant regimen remained significantly associated with an increased risk of aneuploidy in early aborted tissues and embryos [OR (95% CI) 1.767 (1.174, 2.661), OR (95% CI) 1.465 (1.020, 2.102)]. Furthermore, the embryo aneuploidy rate in the GnRH-ant protocol group was significantly higher than that in the GnRH-a long protocol group but only in young and normal ovarian responders [OR (95% CI) 3.54 (1.48, 8.46)].Conclusions: The GnRH-ant protocol is associated with a higher aneuploidy rate in early aborted tissues and embryos than the GnRH-a long protocol in Chinese women. A multicenter, randomized controlled trial would be the optimal strategy to confirm these results.


2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S148-S148
Author(s):  
Marc Salvatus ◽  
Hemi Jung ◽  
Romic Eskandarian ◽  
Su Lee

Abstract Background Experts suggest that a highly sensitive MRSA nasal PCR can be used to rule out MRSA pneumonia with a negative predictive value greater than 95%. At Adventist Health Glendale (AHGL), the MRSA nasal PCR had a 97% negative predictive value. Pharmacist-led de-escalation of MRSA therapy using MRSA nasal PCR may reduce unnecessary MRSA coverage, patient adverse events, and medication costs. The purpose of this study was to assess the impact on duration of antimicrobial therapy of pharmacist-driven de-escalation of MRSA-targeted antibiotics in pneumonia using MRSA nasal PCR. Methods This was a prospective quasi-experimental study (Oct 2018 – Mar 2019 vs. Oct 2019 – Mar 2020) at AHGL, a 515-bed acute care community hospital in Los Angeles, CA, which included adults on MRSA pneumonia agents (either IV vancomycin or IV/PO linezolid). Upon receiving CPOE orders of these MRSA-targeted therapies for pneumonia, the pharmacist ordered a MRSA nasal PCR per protocol for eligible patients, followed up with the results of the MRSA nasal PCR, and recommended to discontinue MRSA therapy if the MRSA nasal PCR was negative. This study received an exemption determination from AHGL IRB. Results The total number of patients in the pre-protocol group was 97, and 155 in the post-protocol group. There was a statistically significant decrease in the median duration of MRSA pneumonia agents from the pre-protocol group compared to the post-protocol group (3 days vs. 2 days, P-value = 0.0004). Additionally, there was a statistically significant decrease in the median hospital length of stay from the pre-protocol group compared to the post-protocol group (9 days vs. 7 days, P-value = 0.02). Conclusion Implementation of a protocol involving pharmacist-led de-escalation of MRSA-targeted antibiotics for pneumonia utilizing MRSA nasal PCR led to significant decreases in both duration of therapy of MRSA-targeted antibiotics and length of hospital stay. Disclosures All Authors: No reported disclosures


2021 ◽  
Author(s):  
Sachiko Takamatsu ◽  
Nobuyuki Kagiyama ◽  
Naohiko Sone ◽  
Kiyotaka Tougi ◽  
Shuichiro Yamauchi ◽  
...  

Abstract Protocols for hemostasis after trans-radial approach (TRA) vary depending on the institute as there is no established evidence-based protocol. This study aimed to investigate the clinical implications of radial compression protocols. Consecutive patients who underwent outpatient invasive catheter angiography before and after April 2018 were treated with traditional and new protocols, respectively. Using the same hemostasis band, the amount and timing of deflation were fixed in the traditional protocol, whereas the air was removed as much as possible every 30 min in the new protocol. A total of 1,842 patients (71±10 years old, 77% male) were included. Compared with the traditional protocol group (n=1,001), the new protocol group (n=841) had a significantly lower rate of dual antiplatelet therapy (24% vs. 35%, p<0.001). The time required for complete hemostasis was approximately one-third with the new protocol (66±32 min vs. 190±16 min, p<0.001) with no clinically relevant bleeding. The incidence of radial artery occlusion (RAO) was 9.8% and 0.9% in the traditional and new protocol groups, respectively (p<0.001). After adjusting for covariates, the new protocol was associated with a shorter hemostasis time (odds ratio 0.01, p<0.001) and a reduced risk of RAO (odds ratio 0.09, p<0.001). Our new protocol for hemostasis after TRA was strongly associated with a shorter hemostasis time and a lower rate of RAO.


Author(s):  
Chetan P Huded ◽  
Anirudh Kumar ◽  
Nicholas Kassis ◽  
Michael J Johnson ◽  
Kathleen Kravitz ◽  
...  

Abstract Aims To determine whether a comprehensive STEMI protocol is associated with reduced sex disparities over 5 years. Methods and Results This was an observational cohort study of 1833 consecutive STEMI patients treated with percutaneous coronary intervention (PCI) before (1/1/2011-7/14/2014, control group) and after (7/15/2014-7/15/2019, protocol group) implementation of a protocol for early guideline-directed medical therapy (GDMT), rapid door to balloon time (D2BT), and use of trans-radial PCI. In the control group females had less GDMT (77.1% vs. 68.1%, p = 0.03), similarly low trans-radial PCI (19.0% vs. 17.6%, p = 0.73), and longer D2BT(104 min [79, 133] vs. 112 min [85, 147], p = 0.02) corresponding to higher in-hospital mortality (4.5% vs. 10.3%, OR 2.44 [1.34-4.46], p = 0.004), major adverse cardiac and cerebrovascular events (MACCE, 9.8% vs. 16.3%, OR 1.79 [1.14-2.84], p = 0.01), and net adverse clinical events (NACE, 16.1% vs. 28.3%, OR 2.06 [1.42-2.99], p &lt; 0.001). In the protocol group, no significant sex differences were observed in GDMT (87.2% vs. 86.4%, p = 0.81) or D2BT (85 min [64, 106] vs. 89 min [65, 111], p = 0.06) but trans-radial PCI was used less in females (77.6% vs. 71.2%, p = 0.03). In-hospital mortality (2.5% vs. 4.4%, OR 1.78 [0.91-3.51], p = 0.09) and MACCE (9.0% vs. 11.0%, OR 1.27 [0.83-1.92], p = 0.26) were similar between sexes, but higher NACE in females approached significance (14.8% vs. 19.4%, OR 1.38 [0.99-1.92], p = 0.05) due to higher bleeding risk (7.2% vs. 11.1%, OR 1.60 [1.04-2.46], p = 0.03). Conclusions A comprehensive STEMI protocol was associated with sustained reductions for in-hospital ischemic outcomes over 5 years, but higher bleeding rates in females persisted.


2021 ◽  
Vol 12 ◽  
Author(s):  
Shan Liu ◽  
Minghui Liu ◽  
Lingxiu Li ◽  
Huanhuan Li ◽  
Danni Qu ◽  
...  

ObjectiveTo verify if patients with deep ovarian suppression following gonadotropin releasing hormone (GnRH) agonist long protocol may benefit from a modified GnRH antagonist protocol based on luteinizing hormone (LH) levels.DesignRetrospective cohort study.SettingUniversity-based hospital.Patients110 patients exhibited ultra-low LH levels during ovarian stimulation using GnRH agonist long protocol.Intervention(s)As all the embryos in the first cycle were exhausted without being pregnant, these patients proposed to undergo a second cycle of ovarian stimulation. 74 of them were treated with a modified GnRH antagonist protocol based on LH levels. Other 36 patients were still stimulated following GnRH agonist long protocol.Main Outcome MeasureThe primary outcome was live birth rate (LBR). The second outcomes were biochemical pregnancy rate, clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR) and cancellation rate.ResultsReproductive outcomes were much better in the modified GnRH antagonist protocol. The OPR and LBR were much higher in the GnRH antagonist protocol group than in the GnRH agonist long protocol group [odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47, 10.61, P=0.018; OR 4.33, 95% CI 1.38, 13.60, P=0.008; respectively]. Meanwhile, the cancellation rate was much lower in the GnRH antagonist protocol group (OR 0.13, 95% CI 0.02, 0.72; P=0.014). Mean LH level during stimulation did not have a predictive value on live birth. However, it was independently associated with the occurrence of ongoing pregnancy (OR 2.70, 95% CI 1.25, 5.85; P=0.01). The results of sensitivity analyses were consistent with the data mentioned above. The patients got completely different and excellent clinical outcomes in their second cycles stimulated with the modified GnRH antagonist protocol.ConclusionPatients with deep ovarian suppression following GnRH agonist long protocol may benefit from a modified GnRH antagonist protocol based on LH levels.


2021 ◽  
Vol 45 (3) ◽  
pp. 165-170
Author(s):  
Gün Burak Tek ◽  
Gül Keskin

Objective: This retrospective study aimed to evaluate the clinical outcomes of the apical plug performed using MTA with or without collagen sponge in immature anterior maxillary teeth with necrotic pulp. Study design: The study included apical obturation of 20 upper incisor teeth from 18 patients and outcomes of 12-month follow-up. The teeth were divided into 2 groups with 10 cases in each group according to the apexification protocol (Group 1; apical plug with MTA, Group 2; collagen sponge and apical plug with MTA). The artificial apical barrier, approximately 4-mm-thick, was created with MTA in each group. Based on clinical and radiographic criteria, the outcome was assessed using the periapical index (PAI) by 2 calibrated investigators. Results: In this study, 3 of the 6 teeth (50%) in Group 1 and 5 of the 8 teeth (62.5%) in Group 2 healed at the 12-month follow-up. However, there was no statistically significant difference between the groups at the post-treatment follow-up times. Conclusion: The use of collagen as an apical matrix prior to the MTA plug can be suggested due to favorable clinical outcomes.


2021 ◽  
Author(s):  
Sezin Erturk Aksakal ◽  
Oya Aldemir ◽  
İnci Kahyaoglu ◽  
İskender Kaplanoğlu ◽  
Serdar Dilbaz

Abstract ObjectiveThis study aimed to compare the IVF outcomes in patients with diminished ovarian reserve stimulated with luteal phase estradiol (E2) priming protocol versus the standard antagonist protocol.MethodsThe study included 603 patients undergoing intracytoplasmic sperm injection cycles (ICSI) with the diagnosis of diminished ovarian reserve (DOR) who were stimulated with the luteal E2 priming protocol (n=181) and the standard antagonist protocol (n=422). Groups were compared in terms of demographic characteristics, ovarian stimulation results, ICSI cycle outcomes, clinical pregnancy, and live birth rates per embryo transfer. ResultsThe duration of ovarian stimulation was longer, and the total gonadotropin dose used was significantly higher (p=0.001) in the E2 priming protocol group than the antagonist protocol group. The number of embryos transferred was higher in the antagonist protocol group compared with the luteal E2 priming protocol group (0.87±0.75 vs. 0.64±0.49; p=001), but there was no statistically significant difference in terms of embryo quality (p>0.05). The cycle cancellation rate and the clinical pregnancy and live birth rates per embryo transfer were similar in both groups.ConclusionsThere was no significant difference between the ICSI outcomes of the patients diagnosed with diminished ovarian reserve stimulated with the antagonist protocol and the luteal E2 priming protocol. The antagonist protocol might be considered more advantageous because of the shorter treatment duration and lower doses of gonadotropin, and it allows more embryos to be transferred. Additional randomized controlled trials are needed to verify these findings.


2021 ◽  
Vol 61 (3) ◽  
pp. 155-64
Author(s):  
Avyandita Meirizkia ◽  
Dewi Rosariah Ayu ◽  
Raden Muhammad Indra ◽  
Dian Puspita Sari

Background With advances in supportive and risk-stratified therapy, the 5-year survival rate of acute lymphoblastic leukemia has reached 85.5%. The ALL-2006 treatment protocol was modified and renamed the ALL-2013 protocol, with dose and duration changes. Objective To compare outcomes of the ALL-2006 and ALL-2013 protocols, with regards to mortality, remission, relapse, and three-year survival rates. Methods This was retrospective cohort study. Subjects were acute lymphoblastic leukemia (ALL) patients treated from 2011 to 2018 in Mohamad Hoesin Hospital, Palembang, South Sumatera. The three-year survival rates, relapse, remission rates and comparison of ALL-2006 and ALL-2013 protocols were analyzed with Kaplan-Meier method. Results Mortality was significantly correlated with age at diagnosis <1 year and >10 years, hyperleukocytosis, and high-risk disease status. Patients aged 1 to 10 years, with leukocyte count <50,000/mm3 and standard-risk status had significantly higher likelihood of achieving remission. Mortality was not significantly different between the ALL-2006 protocol group [70.6%; mean survival 1,182.15 (SD 176.89) days] and the ALL-2013 protocol group [72.1%; mean survival 764.23 (SD 63.49) days]; (P=0.209). Remission was achieved in 39.2% of the ALL-2006 group and 33% of the ALL-2013 group (P>0.05). Relapse was also not significantly different between the two groups (ALL-2006: 29.4% vs. ALL-2013: 17.9%; P>0.05). Probability of death in the ALL-2006 group was 0.3 times lower than in the ALL-2013 group (P<0.05), while that of the high-risk group was 3 times higher. Remission was 2.19 times higher in those with leukocyte <50,000/mm3 compared to those with hyperleukocytosis. In addition, relapse was significantly more likely in high-risk patients (HR 2.96; 95%CI 1.22 to 7.19). Overall, the 3-year survival rate was 33%, with 41.7% in the ALL-2006 group and 30.7% in the ALL-2013 group. Conclusion Three-year survival rate of ALL-2006 protocol is higher than that of ALL-2013 protocol but is not statistically significant.  Age at diagnosis <1 year and >10 years, hyperleukocytosis, and high-risk group are significantly correlated with higher mortality and lower remission rates. However, these three factors are not significantly different in terms of relapse.   


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