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Clinical Journal of the American... Apr 2023Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led... (Review)
Review
Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led to widespread decline in the use of PD for AKI across high-income countries. The lack of familiarity and comfort with the use of PD in critical care settings has also led to lack of use even among those receiving maintenance PD. Many critical care units reflexively convert patients receiving maintenance PD to alternative dialysis therapies at admission. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries. In high-income countries, the coronavirus disease 2019 (COVID-19) pandemic, saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight advantages and disadvantages of PD in critical care settings and indications and contraindications for its use. We provide an overview of literature to support both PD treatment during AKI and its continuation as a maintenance therapy during critical illness. For AKI therapy, we further discuss establishment of PD access, PD prescription management, and complication monitoring and treatment. Finally, we discuss expansion in the use of PD for AKI therapy extending beyond its role during times of resource constraints.
Topics: Adult; Humans; Critical Illness; COVID-19; Acute Kidney Injury; Peritoneal Dialysis; Renal Dialysis
PubMed: 36754063
DOI: 10.2215/CJN.0000000000000059 -
Frontiers in Public Health 2023There is a need for evidence-informed guidance on the use of complementary and alternative medicine (CAM) for insomnia because of its widespread utilization and a lack...
Identifying complementary and alternative medicine recommendations for insomnia treatment and care: a systematic review and critical assessment of comprehensive clinical practice guidelines.
BACKGROUND
There is a need for evidence-informed guidance on the use of complementary and alternative medicine (CAM) for insomnia because of its widespread utilization and a lack of guidance on the balance of benefits and harms. This systematic review aimed to identify and summarize the CAM recommendations associated with insomnia treatment and care from existing comprehensive clinical practice guidelines (CPGs). The quality of the eligible guidelines was appraised to assess the credibility of these recommendations.
METHODS
Formally published CPGs incorporating CAM recommendations for insomnia management were searched for in seven databases from their inception to January 2023. The NCCIH website and six websites of international guideline developing institutions were also retrieved. The methodological and reporting quality of each included guideline was appraised using the AGREE II instrument and RIGHT statement, respectively.
RESULTS
Seventeen eligible GCPs were included, and 14 were judged to be of moderate to high methodological and reporting quality. The reporting rate of eligible CPGs ranged from 42.9 to 97.1%. Twenty-two CAM modalities were implicated, involving nutritional or natural products, physical CAM, psychological CAM, homeopathy, aromatherapy, and mindful movements. Recommendations for these modalities were mostly unclear, unambiguous, uncertain, or conflicting. Logically explained graded recommendations supporting the CAM use in the treatment and/or care of insomnia were scarce, with bibliotherapy, Tai Chi, Yoga, and auriculotherapy positively recommended based on little and weak evidence. The only consensus was that four phytotherapeutics including valerian, chamomile, kava, and aromatherapy were not recommended for insomnia management because of risk profile and/or limited benefits.
CONCLUSIONS
Existing guidelines are generally limited in providing clear, evidence-informed recommendations for the use of CAM therapies for insomnia management due to a lack of high-quality evidence and multidisciplinary consultation in CPG development. More well-designed studies to provide reliable clinical evidence are therefore urgently needed. Allowing the engagement of a range of interdisciplinary stakeholders in future updates of CPGs is also warranted.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=369155, identifier: CRD42022369155.
Topics: Humans; Bibliotherapy; Complementary Therapies; Sleep Initiation and Maintenance Disorders; Yoga; Practice Guidelines as Topic
PubMed: 37397764
DOI: 10.3389/fpubh.2023.1157419 -
American Journal of Health-system... Sep 2022Structural and financial changes in US healthcare are the driving forces reshaping care delivery and the technologies that clinicians use in their practice....
PURPOSE
Structural and financial changes in US healthcare are the driving forces reshaping care delivery and the technologies that clinicians use in their practice. Structural-level changes in healthcare organizations bringing facilities varying in size, systems, and complexity under the new integrated care delivery networks create unprecedented challenges. This paper develops guiding principles for formulary management in automated systems that facilitate medication management and alignment of medication information technology (IT) solutions in healthcare organizations ranging in size from a single facility to very large enterprise/multifacility networks.
SUMMARY
This paper describes formulary management best practices for healthcare organizations as they follow crucial medication management processes: formulary item builds, urgent and nonformulary medication requests, and formulary item build testing and maintenance. As medication management practices are embedded in automated technologies that are similar yet nuanced, we pay special attention to practices and change control processes that maximize coordination among systems while preserving medication data integrity and reducing medication errors.
CONCLUSION
For increasingly complex healthcare systems with multiple medication management system demands, formulary drug database builds and maintenance are challenging and time-consuming. Formulary item build, testing, and maintenance processes involve multifunctional teams collaborating to ensure the integrity of data, prevent unexpected system incompatibilities, and improve patient safety by reducing medication errors. Ideally, formulary item build, testing, and maintenance processes produce consistent final drug records in IT systems meeting user needs.
Topics: Delivery of Health Care, Integrated; Humans; Medication Errors; Patient Safety
PubMed: 35552370
DOI: 10.1093/ajhp/zxac123 -
Critical Reviews in Oncology/hematology Nov 2019Through the last three decades, the combination of paclitaxel and carboplatin remains the standard of care chemotherapy in newly diagnosed epithelial ovarian cancer... (Review)
Review
Through the last three decades, the combination of paclitaxel and carboplatin remains the standard of care chemotherapy in newly diagnosed epithelial ovarian cancer (EOC). Based on a single trial, first-line maintenance therapy with angiogenesis inhibitor bevacizumab was approved in Europe and widely applied. In 2018, based on a second trial bevacizumab was approved for first-line maintenance in the United States. Despite complete remission upon chemotherapy, the majority of the patients recur. A large number of randomized trials were conducted to explore the optimal front-line therapy regimen, but neither dose-densing, nor adding of a third chemotherapy agent or intraperitoneal administration could improve overall survival (OS). Also implementation of hyperthermic intraperitoneal chemotherapy (HIPEC) or the neoadjuvant approach failed to improve OS. Recently, maintenance therapy with PARP inhibitors showed encouraging results in patients with BRCA1/2 mutation. Further trials with targeted therapies are ongoing. Here we review the achievements of front-line therapy in primary advanced EOC through the last three decades and discuss future treatment strategies.
Topics: Antineoplastic Combined Chemotherapy Protocols; Carcinoma, Ovarian Epithelial; Female; Humans; Hyperthermia, Induced; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Ovarian Neoplasms; Randomized Controlled Trials as Topic; Treatment Failure; Treatment Outcome
PubMed: 31449982
DOI: 10.1016/j.critrevonc.2019.08.002 -
Maintenance Therapy in Metastatic Solid Tumors: Innovative Strategy or Simple Second-line Treatment?American Journal of Clinical Oncology Aug 2019Managing metastatic diseases involves defining the best strategy that is supposed to take into account both efficacy and quality of life. To this end, clinicians use... (Review)
Review
Managing metastatic diseases involves defining the best strategy that is supposed to take into account both efficacy and quality of life. To this end, clinicians use stop and go or maintenance strategies. As a matter of fact, 2 maintenance strategies can be distinguished: continuation maintenance using a drug already present in induction treatment and switch maintenance with a newly introduced drug. Several drugs have been approved as maintenance therapy with several current indications in solid tumors. Questions remain concerning such strategies, notably duration, cost, tolerability, and shortcut between switch maintenance and early second line. If the concept of maintenance strategy remains trendy with numerous trials ongoing, several issues are still pending. The aims of this review were to accurately define and describe the various facets of maintenance therapy through its several indications in real life and then to discuss the future challenges of maintenance therapy in oncology.
Topics: Antineoplastic Agents; Disease Progression; Drug Substitution; Humans; Immunotherapy; Maintenance Chemotherapy; Neoplasms
PubMed: 31313680
DOI: 10.1097/COC.0000000000000574 -
Cancer Jul 2023Lenalidomide maintenance after autologous stem cell transplant (ASCT) in multiple myeloma (MM) results in superior progression-free survival and overall survival....
BACKGROUND
Lenalidomide maintenance after autologous stem cell transplant (ASCT) in multiple myeloma (MM) results in superior progression-free survival and overall survival. However, patients with high-risk multiple myeloma (HRMM) do not derive the same survival benefit from lenalidomide maintenance compared with standard-risk patients. The authors sought to determine the outcomes of bortezomib-based maintenance compared with lenalidomide maintenance in patients with HRMM undergoing ASCT.
METHODS
In total, the authors identified 503 patients with HRMM who were undergoing ASCT within 12 months of diagnosis from January 2013 to December 2018 after receiving triplet novel-agent induction in the Center for International Blood and Marrow Transplant Research database. HRMM was defined as deletion 17p, t(14;16), t(4;14), t(14;20), or chromosome 1q gain.
RESULTS
Three hundred fifty-seven patients (67%) received lenalidomide alone, and 146 (33%) received bortezomib-based maintenance (with bortezomib alone in 58%). Patients in the bortezomib-based maintenance group were more likely to harbor two or more high-risk abnormalities and International Staging System stage III disease (30% vs. 22%; p = .01) compared with the lenalidomide group (24% vs. 15%; p < .01). Patients who were receiving lenalidomide maintenance had superior progression-free survival at 2 years compared with those who were receiving either bortezomib monotherapy or combination therapy (75% vs. 63%; p = .009). Overall survival at 2 years was also superior in the lenalidomide group (93% vs. 84%; p = .001).
CONCLUSIONS
No superior outcomes were observed in patients with HRMM who received bortezomib monotherapy or (to a lesser extent) in those who received bortezomib in combination as maintenance compared with lenalidomide alone. Until prospective data from randomized clinical trials are available, post-transplant therapy should be tailored to each patient with consideration for treating patients in clinical trials that target novel therapeutic strategies for HRMM, and lenalidomide should remain a cornerstone of treatment.
Topics: Humans; Multiple Myeloma; Lenalidomide; Bortezomib; Prospective Studies; Hematopoietic Stem Cell Transplantation; Antineoplastic Combined Chemotherapy Protocols; Transplantation, Autologous; Dexamethasone
PubMed: 37021929
DOI: 10.1002/cncr.34778 -
Dermatologic Therapy Nov 2021Psoriasis (PsO) requires safe and effective long-term management to reduce the risk of recurrence and decrease the frequency of relapse. Topical PsO therapies are a... (Review)
Review
Psoriasis (PsO) requires safe and effective long-term management to reduce the risk of recurrence and decrease the frequency of relapse. Topical PsO therapies are a cornerstone in the management of PsO though safety concerns limit the chronic, continuous use of topical corticosteroids and/or vitamin D analogs. Evidence-based guidelines on optimal treatment targets and maintenance therapy regimens are currently lacking. This review explores the evidence supporting approaches to maintenance topical therapy for PsO including continuous long-term therapy, chronic intermittent use, step-down therapy, sequential or pulse therapy regimens, and proactive maintenance therapy. Several unaddressed questions are discussed including how and when to transition from acute to maintenance therapy, strategies for monitoring long-term treatment, the role of topical maintenance therapy in the context of systemic and biologic therapies, risks of maintenance therapy, prescribing a topical preparation suitable for patients' preferences and skin type, and key concepts for patient education to maximize long-term outcomes. Overall, emerging evidence supports a paradigm shift toward proactive treatment once skin is completely clear as a strategy to enhance disease control without compromising safety.
Topics: Administration, Topical; Cholecalciferol; Dermatologic Agents; Glucocorticoids; Humans; Psoriasis
PubMed: 34418251
DOI: 10.1111/dth.15104 -
Annals of Allergy, Asthma & Immunology... Oct 2023A "window of opportunity" has been proposed where anti-inflammatory therapy administration in response to symptoms could prevent exacerbation.
BACKGROUND
A "window of opportunity" has been proposed where anti-inflammatory therapy administration in response to symptoms could prevent exacerbation.
OBJECTIVE
To evaluate rescue and maintenance therapy claims surrounding a severe asthma exacerbation serious enough to require a face-to-face clinical encounter.
METHODS
Merative MarketScan research databases (US administrative claims 2011 to 2017) were analyzed for patients aged ≥4 years, with an asthma diagnosis code, who filled short-acting β-agonist (SABA) and Global Initiative for Asthma Steps 3 to 5 maintenance therapies. Patients were indexed on a random SABA claim and had 12 months' continuous health plan eligibility pre- and post-index. Serious exacerbations were severe exacerbations requiring systemic corticosteroids prescribed from an outpatient clinic, urgent care or emergency department, or hospitalization for asthma. SABA and maintenance claims 30 days pre- and post-event were analyzed.
RESULTS
Of 319,342 patients (30% children 4 to 11 years; 70% adults or adolescents ≥12 years), 27.2% of children and 16.8% of adolescents or adults experienced ≥ 1 serious exacerbation (unadjusted odds ratio [OR], 1.85 [95% confidence interval, 1.81-1.88]). In the 30 days pre-event, 42.6% filled ≥1 SABA (children: 44.3%; adolescents or adults: 41.5%; OR, 1.12 [1.09-1.16]) and 57.4% filled maintenance (children: 59.0%; adolescents or adults: 56.3%; OR, 1.12 [1.08-1.15]). In the 30 days post-event, 61.4% filled SABA (children: 69.7%; adolescents or adults: 55.6%; OR, 1.84 [1.78-1.90]) and 94.8% filled maintenance (children: 98.6%; adolescents or adults: 92.2%; OR, 6.09 [5.45-6.81]).
CONCLUSION
Many patients treated as having moderate-to-severe asthma escalate SABA claims before a serious exacerbation, but approximately 40% have no anti-inflammatory maintenance fill, highlighting a "window of opportunity" to prevent exacerbations using inhaled corticosteroids concomitantly with SABA as rescue.
Topics: Adult; Child; Adolescent; Humans; Anti-Asthmatic Agents; Asthma; Adrenal Cortex Hormones; Administration, Inhalation; Hospitalization
PubMed: 37343824
DOI: 10.1016/j.anai.2023.06.018 -
Blood Cancer Journal Sep 2023Autologous stem cell transplant (ASCT) remains an important option for eligible multiple myeloma (MM) patients as part of initial therapy. Using the Canadian Myeloma...
Autologous stem cell transplant (ASCT) remains an important option for eligible multiple myeloma (MM) patients as part of initial therapy. Using the Canadian Myeloma Research Group (CMRG) national database, we examined the details and outcomes of ASCT performed as first-line therapy in eligible Canadian MM patients between 2007 to 2021. We included 3821 patients with 72% receiving CyBorD induction and 2061 patients receiving maintenance, consisting of lenalidomide +/- steroids in 78.3%. The median PFS and OS for patients given a single ASCT were 35.4 and 126 months. Those receiving a second induction regimen had significantly inferior outcomes, although when maintenance was used, results were comparable regardless of the number of induction regimens administered (median PFS 55.3 vs 51.1 months [p = 0.11]; median OS 158.6 vs not yet reached [p = 0.13]). Consolidation patients had a longer median PFS (55.3 vs 34.4 months [p = 0.001]), but no significant gain in median OS (p = 0.065). Patients who received lenalidomide-based maintenance experienced a median PFS of 53.7 months and OS of 159 months. In the multivariable analysis, use of any type of maintenance therapy vs no maintenance was associated with a lower risk of progression (HR 0.52 (95% CI 0.47-0.57)) and death (HR 0.58 (95% CI 0.51-0.67)). This real-world study demonstrates that, overall, first-line treatment sequence in transplant-eligible patients produces a median OS of ≥10 years. It also highlights the contribution of post-ASCT maintenance, particularly lenalidomide given until progression.
Topics: Humans; Hematopoietic Stem Cell Transplantation; Multiple Myeloma; Transplantation, Autologous; Lenalidomide; Canada; Stem Cell Transplantation
PubMed: 37669949
DOI: 10.1038/s41408-023-00905-8 -
International Journal of Hematology Jul 2023Allogeneic hematopoietic stem cell transplant (HCT) has improved survival for patients with acute myeloid leukemia (AML), especially for those at high risk of relapse.... (Review)
Review
Post-transplant maintenance therapy in acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation harmonizing multiple therapeutic modalities including targeted therapy, immunotherapy and cellular therapy.
Allogeneic hematopoietic stem cell transplant (HCT) has improved survival for patients with acute myeloid leukemia (AML), especially for those at high risk of relapse. However, relapse remains the leading cause of treatment failure post-HCT, occurring in around 35-45% of patients, and leading to dismal outcomes. Strategies to reduce relapse risk are urgently needed, especially in the early post-transplant period before activation of the graft-versus-leukemia (GVL) effect. Maintenance therapy is a course of treatment given post-HCT with the expectation of reducing relapse risk. While there are currently no therapies approved for maintenance therapy for AML after HCT, there are a number of studies and ongoing investigations examining the role of maintenance therapies that include targeted agents against FLT3-ITD, BCL2, or IDH mutations, hypomethylating agents, immunomodulatory therapies and cellular therapies. In this review, we discuss the mechanistic and clinical data for post-transplant maintenance therapies in AML and strategies for maintenance therapy for AML after HCT.
Topics: Humans; Antineoplastic Agents; Immunotherapy; Hematopoietic Stem Cell Transplantation; Leukemia, Myeloid, Acute; Recurrence
PubMed: 37212948
DOI: 10.1007/s12185-023-03614-x