2 Minute Medicine Rewind April 18, 2016

PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck Cancer

The management of locally advanced squamous cell head and neck cancer involves the combination of chemotherapy and radiation and surgery. The additional benefit of surgery after neoadjuvant chemoradiation is questioned as some clinicians favor active surveillance with PET-CT imaging instead of going directly to neck dissection. In this multicenter noninferiority randomized trial of 564 patients with N2 and N3 squamous cell carcinoma of the head and neck, investigators randomized patients to either planned neck dissection or surveillance with PET-CT which can result in subsequent neck dissection surgery. The overall two year survival similar and noninferior (84.9% for PET-CT surveillance vs. 81.5% for planned surgery, p = 0.004 for non-inferiority). The utilization of neck dissection was significantly reduced in the PET-CT surveillance arm (54 vs. 221) and was estimated to save approximately $2,190 per patient during the study period. In this study of locally advanced squamous cell head and neck patients in the United Kingdom, active surveillance with PET-CT after chemoradiation was noninferior to planned neck dissection.

Incidence, Risk Factors, and Attributable Mortality of Secondary Infections in the Intensive Care Unit After Admission for Sepsis

Nosocomial infections are considered preventable adverse events in the hospital, with catheter associated infections deemed “never events” by the Joint Commission, however sepsis is thought to suppress the immune system and increase susceptibility to secondary infections. In this prospective cohort trial of two ICUs in the Netherlands, investigators recruited 1719 patients admitted to the ICU for sepsis and 1921 patients for diagnoses other than sepsis and evaluated patient profiles and blood gene expression. In this cohort, 13.5% of sepsis ICU admissions had a secondary infection and 15.1% of non-sepsis ICU admissions had a secondary infection. Patients who developed secondary infection appeared to have higher disease severity on admission (APACHE score 90 vs. 71, p < 0.001) than patients who did not develop secondary infection. Comparing baseline blood gene expression and blood gene expression at the start of secondary infection, there was decreased expression of genes associated with gluconeogenesis and glycolysis. In this study, patients with sepsis of higher severity were more likely to develop secondary ICU infection.

Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program

Reducing hospital readmissions has been an important cost-lowering effort across the USA and Canada. However, despite numerous program efforts, readmissions rates have not been significantly lowered. This quasi-experimental study aimed to evaluate whether overall Medicare FFS readmissions were reduced through application of a personalized transitional care intervention applied to high-risk discharge patients. Thirty-day unplanned same-hospital readmission rates of high-risk Medicare FFS patients assigned to the personalized transitional care intervention had a reduction of about ten percent relative to the control group. This represented about fifty patients who would need to receive this transitional care to prevent one readmission. Although this study showed a positive impact on reducing readmission rates in this high-risk population, it did not achieve the pre-specified goal reduction target set by the CMS (20%). Further risk stratification amongst the patients or a different form of transitional care may improve on these results in the future.

Aspirin for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: A Decision Analysis for the U.S. Preventive Services Task Force

While strong evidence exists to support the effectiveness of aspirin in secondary prevention of complications from heart disease and stroke, evidence for the net benefit of aspirin in preventing cardiovascular disease (CVD) and colorectal cancer (CRC) is less clear. This study evaluates three recent systematic reviews conducted on behalf of the U.S. Preventive Services Task Force (USPSTF) to evaluate the benefits and harms of long-term aspirin use in primary prevention for CVD and CRC. Collectively, the reviews affirmed a positive lifetime benefit in aspirin use for all sex and baseline CVD risk groups aged 40 to 60, while a negative lifetime benefit was observed for patients of all risk levels aged 70 to 79. Additionally, aspirin’s protective effect for CRC was lowest when aspirin was initiated at older ages. This study may be limited by its estimates of how age, sex, aspirin, and other possible risk factors interact to affect GI bleeding and case-fatality rates. Overall, the study suggests that while adults aged 40 to 60 may benefit from aspirin primary prevention of CVD and CRC, the harms might outweigh the benefits in an older population.

Image: PD

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