IBRUTINIB FOR CONTROL OF CHOROIDAL AND ORBITAL METASTASIS FROM CHRONIC LYMPHOCYTIC LEUKEMIA.

PURPOSE: To describe a case of choroidal and orbital metastasis of chronic lymphocytic leukemia controlled with ibrutinib monotherapy, an oral tyrosine kinase inhibitor. METHODS: Single case report. RESULTS: A 69-year-old man with a past medical history of chronic lymphocytic leukemia diagnosed 1 year previously was referred with a foveal lesion in the right eye and was found to have hyperopic shift in the right eye. Optical coherence tomography demonstrated choroidal infiltration in the right eye, and computed tomography of the orbits demonstrated a left orbital mass. Biopsy of the left orbital mass confirmed chronic lymphocytic leukemia/small lymphocytic leukemia. Oral ibrutinib monotherapy of 140 mg three times daily was initiated for treatment of these choroidal and orbital metastases, and at 6 months, there was clinical resolution of disease. Cessation of ibrutinib monotherapy was followed 7 months later by recurrence of choroidal disease. Reinitiation of ibrutinib monotherapy 140 mg three times daily led again to clinical disease resolution, and durable remission has been attained on a well-tolerated low maintenance dose of ibrutinib 140 mg two times daily. CONCLUSION: This is the first reported case of control of choroidal and orbital metastasis of chronic lymphocytic leukemia with ibrutinib monotherapy, confirmed with choroidal recurrence on drug cessation and clinical resolution of disease on re-treatment.

Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression.

OBJECTIVES: To demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital microsystems and macrosystems. METHODS: Ordinary least squares and panel data regression of retrospective hospital billing data, and SPC charts of prospective patient records for a US tertiary-care facility (2004-2007). A prospective cohort of hospital inpatients at risk for HAPUs was the study population. RESULTS: There were 337 HAPU incidences hospital wide among 43 844 inpatients. A probit regression model predicted the correlation of age, gender and length of stay on HAPU incidence (pseudo R(2)=0.096). Panel data analysis determined that for each additional day in the hospital, there was a 0.28% increase in the likelihood of HAPU incidence. A p-chart of HAPU incidence showed a mean incidence rate of 1.17% remaining in statistical control. A t-chart showed the average time between events for the last 25 HAPUs was 13.25 days. There was one 57-day period between two incidences during the observation period. A p-chart addressing Braden scale assessments showed that 40.5% of all patients were risk stratified for HAPUs upon admission. CONCLUSION: SPC charts complement standard regression analysis. SPC amplifies patient outcomes at the microsystem level and is useful for guiding quality improvement. Macrosystems should monitor effective quality improvement initiatives in microsystems and aid the spread of successful initiatives to other microsystems, followed by system-wide analysis with regression. Although HAPU incidence in this study is below the national mean, there is still room to improve HAPU incidence in this hospital setting since 0% incidence is theoretically achievable. Further assessment of pressure ulcer incidence could illustrate improvement in the quality of care and prevent HAPUs.

Intravitreal triamcinolone acetonide injection for treatment of refractory diabetic macular edema: a systematic review.

OBJECTIVE: To compare intravitreal triamcinolone acetonide (IVTA) injection versus no treatment or sub-Tenon triamcinolone acetonide (STTA) injection in improving visual acuity (VA) of patients with refractory diabetic macular edema (DME; unresponsive to focal laser therapy). CLINICAL RELEVANCE: Diabetic macular edema is the leading cause of visual loss in diabetic retinopathy. Laser therapy has been the standard of care for patients with persistent or progressive disease. More recently, it has been suggested that IVTA injection may improve VA. METHODS AND LITERATURE REVIEWED: The following databases were searched: Medline (1950-September Week 2 2008), The Cochrane Library (Issue 3, 2008), and the TRIP Database (up to September 1, 2008), using no language or other limits. Randomized controlled trials were included that consisted of patients with refractory DME, those comparing IVTA injection with no treatment or STTA injection, those reporting VA outcomes, and those having a minimum follow-up of 3 months. RESULTS: In the 4 randomized clinical trials comparing IVTA injection with placebo or no treatment, IVTA injection demonstrated greater improvement in VA at 3 months, but the benefit was no longer significant at 6 months. Those who received IVTA injection had significantly higher IOP at 3 months and at 6 months. In the 2 randomized clinical trials comparing IVTA injection with STTA injection, IVTA injection demonstrated greater improvement in VA at 3 months, but not at 6 months. Intravitreal triamcinolone acetonide injection demonstrated no difference in IOP at 3 months or at 6 months. CONCLUSIONS: Intravitreal triamcinolone acetonide injection is effective in improving VA in patients with refractory DME in the short-term, but the benefits do not seem to persist in the long-term. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.