Oral fluoroquinolones for definitive treatment of gram-negative bacteremia in cancer patients.

PURPOSE: Bloodstream infections (BSI) are significant causes of morbidity and mortality in cancer patients. These patients often receive 10 to 14 days of intravenous (IV) antibiotics. The objective of this study was to compare the outcomes of cancer patients transitioned from IV to oral (PO) therapy compared to continuation of IV treatment. METHODS: This was a single-center, retrospective cohort study of hospitalized adult cancer patients with gram-negative bacteremia. Patients transitioned to a PO fluoroquinolone (FQ) within 5 days were allocated to the IV-to-PO group, while the remaining patients comprised the IV group. The primary outcome was the composite of treatment failure, defined as infection-related readmission, infection recurrence, or inpatient mortality. A multivariable logistic regression model was constructed to account for confounding variables. Secondary outcomes assessed included infection-related length of stay (LOS), hospital LOS, and adverse events, such as Clostridioides difficile infection and catheter-related complications. RESULTS: The IV-to-PO group included 78 patients, while the remaining 133 patients were allocated to the IV group. Differences at baseline included more hematologic malignancy, neutropenia, ICU admissions, and higher Pitt bacteremia scores in the IV group. The rate of treatment failure was significantly higher in the IV group (24% vs 9%; p < 0.01), which persisted in the logistic regression (aOR 3.5, 95% CI 1.3-9.1). The IV-to-PO group had decreased infection-related and hospital length of stay, as well as fewer catheter-related complications. CONCLUSIONS: The use of PO FQ may be considered for the definitive treatment of uncomplicated Enterobacterales BSI in cancer patients.

Daunorubicin and Cytarabine Liposome in Newly Diagnosed Therapy-Related Acute Myeloid Leukemia (AML) or AML With Myelodysplasia-Related Changes.

OBJECTIVE: To evaluate the efficacy and safety of daunorubicin and cytarabine liposome in older adults with newly diagnosed therapy-related acute myeloid leukemia (t-AML) or AML with myelodysplasia-related changes (AML-MRC). DATA SOURCE: A literature search of PubMed and MEDLINE (January 2017 to January 2018) was performed using the terms CPX-351, Vyxeos, daunorubicin and cytarabine liposome, and acute myeloid leukemia. STUDY SELECTION/DATA EXTRACTION: Phase I, II, and III clinical trials evaluating the efficacy and safety of daunorubicin and cytarabine liposome were reviewed with a specific focus on its use in older patients with newly diagnosed AML. All peer-reviewed articles with clinically relevant information were evaluated for inclusion. DATA SYNTHESIS: The phase II trial demonstrated that daunorubicin and cytarabine liposome improved response rates (RR), but there was no difference in event-free survival and overall survival in the overall patient population. However, clinical benefit was most pronounced in secondary AML with an increased RR and survival. The phase III trial illustrated that daunorubicin and cytarabine liposome improved survival and RR with tolerable toxicity compared with standard 7 plus 3 (daunorubicin and cytarabine) in patients 60 to 75 years of age with t-AML or AML-MRC. More patients proceeded to a stem cell transplant, and 30-day and 60-day mortality was lower with daunorubicin and cytarabine liposome. Grade 3 to 5 toxicities were similar between the 2 groups, except daunorubicin and cytarabine liposome had prolonged cytopenia and a higher risk of hemorrhage. CONCLUSIONS: Daunorubicin and cytarabine liposome improves RR and survival, with tolerable toxicity in older patients with t-AML or AML-MRC.

Midostaurin in Combination With Standard Chemotherapy for Treatment of Newly Diagnosed FMS-Like Tyrosine Kinase 3 (FLT3) Mutation-Positive Acute Myeloid Leukemia.

OBJECTIVE: To evaluate the efficacy and safety of midostaurin in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation in newly diagnosed FLT3-mutated acute myeloid leukemia (AML). DATA SOURCE: A literature search of PubMed and MEDLINE (September 2017) was performed using the terms midostaurin, PKC412, FLT3 gene, and acute myeloid leukemia. STUDY SELECTION/DATA EXTRACTION: Clinical trials evaluating the efficacy and safety of midostaurin in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation were reviewed for the treatment of newly diagnosed FLT3-mutated AML. All peer-reviewed articles with clinically relevant information were evaluated for inclusion. DATA SYNTHESIS: Midostaurin is a multikinase inhibitor also targeting FLT3 indicated for the treatment of newly diagnosed FLT3-mutated AML. A phase III trial illustrated that midostaurin in combination with standard chemotherapy improved event-free survival, disease-free survival, and overall survival in patients with newly diagnosed FLT3-mutation-positive AML compared with standard chemotherapy alone. However, midostaurin did not show a difference in the rate of patients who proceeded to receive an allogeneic stem cell transplant compared with placebo. There was no significant difference in toxicity between the midostaurin and placebo groups, except that more patients experienced grade 3 to 5 anemia and rash with midostaurin. CONCLUSIONS: Midostaurin in combination with standard induction and consolidation is safe and efficacious in newly diagnosed FLT3-mutated AML.

Enasidenib: An Oral IDH2 Inhibitor for the Treatment of Acute Myeloid Leukemia.

Acute myeloid leukemia (AML) is a hematologic malignancy that affects predominantly older patients, with a median age of diagnosis around 67. Overall prognosis is poor; however, novel targeted therapies that can potentially improve outcomes in these patients have emerged in recent years. Mutations in isocitrate dehydrogenase (IDH) occur in 20% of AML diagnoses. IDH2 performs a crucial role in cellular metabolism, and when this enzyme is inhibited, the cell cannot rid itself of endogenous products and is thus marked for apoptosis. The US Food and Drug Administration (FDA) approved the first mutant IDH2 inhibitor, enasidenib, for patients with relapsed or refractory IDH2-mutated AML detected by an FDA-approved test.

Inotuzumab Ozogamicin in Relapsed or Refractory B-Cell Acute Lymphoblastic Leukemia.

Despite initial complete remission rates of up to 90%, long-term, disease-free survival remains poor in patients with newly diagnosed acute lymphoblastic leukemia (ALL). Response to salvage chemotherapy is suboptimal; therefore, novel therapeutic agents are being investigated in order to improve outcomes in these patients. Inotuzumab ozogamicin is a CD22-directed antibody-drug conjugate recently approved by the US Food and Drug Administration for the treatment of adults with relapsed or refractory B-cell precursor ALL. Inotuzumab ozogamicin improves response rate, minimal residual disease negativity, and survival compared to standard chemotherapy in this population. In addition, it offers more opportunities to proceed to an allogeneic stem cell transplant in patients who otherwise may not be candidates.

Confidence of Nursing Personnel in Their Understanding Of the Psychosocial Impact of Prostate Cancer.

Nurses must be equipped with skills to support men diagnosed with prostate cancer. Implementation of a unit-specific, evidence-based education program had significant, positive effects on the confidence of nurses who care for veterans who experience a psychosocial impact of prostate cancer treatment.

Doppler-detected valve movement in aortic stenosis: a predictor of adverse outcome.

BACKGROUND: The absence of auscultatory aortic valve closure sound is associated with severe aortic stenosis. The absence of Doppler-derived aortic opening (Aop ) or closing (Acl ) may be a sign of advanced severe aortic stenosis. HYPOTHESIS: Absent Doppler-detected Aop or Acl transient is indicative of very severe aortic stenosis and is associated with adverse outcome. METHODS: A total of 118 consecutive patients with moderate (n = 63) or severe aortic stenosis (n = 55) were included. Aop and Acl signals were identified in a blinded fashion by continuous-wave Doppler. Patients with and without Aop and Acl were compared using χ(2) test for dichotomous variables and analysis of variance for continuous variables. The associations of Aop and Acl with aortic valve replacement were determined. RESULTS: Aop or Acl were absent in 22 of 118 patients. The absence of Aop or Acl was associated with echocardiographic parameters of severe aortic stenosis. The absence of Aop or Acl was associated with incident aortic valve replacement (36.4% vs 7.3%, respectively, P < 0.001). Even in patients with aortic valve area <1 cm(2) , the absence of Aop or Acl was still associated with increased rate of aortic valve replacement (42.1% vs 13.9%, respectively, P = 0.019) and provided incremental predictive value over peak velocity. CONCLUSIONS: In a typical population of patients with aortic stenosis, approximately 1 in 6 has no detectible aortic valve opening or closing Doppler signal. The absence of an Aop or Acl signal is a highly specific sign of severe aortic stenosis and is associated with incident aortic valve replacement.

Relationships between watershed emergy flow and coastal New England salt marsh structure, function, and condition.

This study evaluated the link between watershed activities and salt marsh structure, function, and condition using spatial emergy flow density (areal empower density) in the watershed and field data from 10 tidal salt marshes in Narragansett Bay, RI, USA. The field-collected data were obtained during several years of vegetation, invertebrate, soil, and water quality sampling. The use of emergy as an accounting mechanism allowed disparate factors (e.g., the amount of building construction and the consumption of electricity) to be combined into a single landscape index while retaining a uniform quantitative definition of the intensity of landscape development. It expanded upon typical land use percentage studies by weighting each category for the intensity of development. At the RI salt marsh sites, an impact index (watershed emergy flow normalized for marsh area) showed significant correlations with mudflat infauna species richness, mussel density, plant species richness, the extent and density of dominant plant species, and denitrification potential within the high salt marsh. Over the 4-year period examined, a loading index (watershed emergy flow normalized for watershed area) showed significant correlations with nitrite and nitrate concentrations, as well as with the nitrogen to phosphorus ratios in stream discharge into the marshes. Both the emergy impact and loading indices were significantly correlated with a salt marsh condition index derived from intensive field-based assessments. Comparison of the emergy indices to calculated nitrogen loading estimates for each watershed also produced significant positive correlations. These results suggest that watershed emergy flow is a robust index of human disturbance and a potential tool for rapid assessment of coastal wetland condition.

Antithrombotic drugs for prevention of recurrent stroke.

Stroke is the third most common cause of adult mortality in the United States. Antithrombotic agents form the mainstay of stroke preventive therapy. Aspirin produces a modest reduction in the risk of secondary stroke and is widely recommended for initial administration. The thienopyridines, ticlopidine and clopidogrel, are useful alternatives for secondary stroke prevention in patients who do not respond to or cannot take aspirin. They have not been proven more clinically effective than aspirin and have been associated with thrombotic thrombocytopenic purpura. The combination of aspirin and ER-dipyridamole offers multiple mechanisms of action and an additive effect on stroke risk reduction compared with either agent alone. A twofold increase in risk reduction and a favorable safety profile suggest that the combination can be used as a first-line agent in a prophylactic regimen for secondary stroke.