Therapeutic decisions in a cohort of patients with idiopathic pulmonary fibrosis: a multicenter, prospective survey from Poland.

Background: Pirfenidone and nintedanib are considered as the standard of care in idiopathic pulmonary fibrosis (IPF), but there is no consensus as to which of these two agents should be regarded as first-line treatment. Objective: To provide real-world data on therapeutic decisions of pulmonary specialists, particularly the choice of the antifibrotic drug in patients with IPF. Methods: This was a multicenter, prospective survey collecting clinical data of patients with IPF considered as candidates for antifibrotic treatment between September 2019 and December 2020. Clinical characteristics and information on the therapeutic approach were retrieved. Statistical evaluation included multiple logistic regression analysis with stepwise model selection. Results: Data on 188 patients [74.5% male, median age 73 (interquartile range, 68-78) years] considered for antifibrotic therapy were collected. Treatment was initiated in 138 patients, while 50 patients did not receive an antifibrotic, mainly due to the lack of consent for treatment and IPF severity. Seventy-two patients received pirfenidone and 66 received nintedanib. Dosing protocol (p < 0.01) and patient preference (p = 0.049) were more frequently associated with the choice of nintedanib, while comorbidity profile (p = 0.0003) and concomitant medication use (p = 0.03) were more frequently associated with the choice of pirfenidone. Age (p = 0.002), lung transfer factor for carbon monoxide (TLCO) (p = 0.001), and gastrointestinal bleeding (p = 0.03) were significantly associated with the qualification for the antifibrotic treatment. Conclusion: This real-world prospective study showed that dose protocol and patient preference were more frequently associated with the choice of nintedanib, while the comorbidity profile and concomitant medication use were more frequently associated with the choice of pirfenidone. Age, TLCO, and history of gastrointestinal bleeding were significant factors influencing the decision to initiate antifibrotic therapy.

Comparison of two Anti Snake Venom protocols in hemotoxic snake bite: A randomized trial.

The dose of Anti Snake Venom (ASV) in hemotoxic snake bite depends on the amount of venom injected and species of snake. All trials in South East Asia have studied different doses of ASV, wherein the ASV in high dose group itself was lower than the dose that is recommended in Indian National protocol. These studies favored low dose protocol, as there was no difference in mortality and morbidity between the groups. So, this study intended to assess the efficacy of National protocol in reducing morbidity and mortality in hemotoxic snake bite in comparison to current protocol followed in institution. This was an open label randomized trial of 140 hemotoxic snakebite patients. Group A received national protocol: initial dose of 100 ml followed by 100 ml 6th hourly till 20-min Whole Blood Clotting Time (20WBCT) was negative or 300 ml of ASV was given, whichever was earlier. Group B received 70 ml followed by 30 ml every 6th hourly until two consecutive 20WBCT were negative. There was no statistical difference in the amount of ASV required in both the groups. Mortality and acute kidney injury were higher in group A (statistically not significant), probably due to sicker patients in that group. There was no relapse of clotting time abnormality in both the groups. In a significant number of patients (12%), clotting time was persistently prolonged till death. We found that the use of National ASV dosing protocol did not decrease the mortality and morbidity.

Validation of a Weight Threshold-Based Vancomycin Dosing Protocol for Patients Undergoing Intermittent Hemodialysis.

BACKGROUND: Patients receiving intermittent hemodialysis (IHD) are at high risk of acquiring gram-positive infections, which are often treated with IV vancomycin. Despite frequent use of vancomycin in the IHD setting, there is variability in dosing and monitoring practices among clinicians at the study institution. There is also a paucity of evidence regarding optimal vancomycin dosing to achieve target pre-IHD serum concentration. OBJECTIVES: The primary objective was to compare the percentage of treatment courses with a serum vancomycin concentration between 15 and 20 mg/L, measured before the third IHD session, before and after implementation of a weight threshold-based dosing protocol. The secondary objectives were to compare the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L and the number of vancomycin measurements per treatment day, before and after protocol implementation. METHODS: This quasi-experimental, single-centre study included inpatients and outpatients who underwent IHD and received at least 2 IV doses of vancomycin, with vancomycin being measured in an appropriately drawn sample before the third IHD session. Before protocol implementation, vancomycin dosing was at the clinician's discretion (usual care). After protocol implementation, each patient received a loading dose of 1000, 1500, or 2000 mg and a maintenance dose of 500, 750, or 1000 mg, depending on body weight. RESULTS: The percentage of treatment courses with a pre-third IHD vancomycin concentration between 15 and 20 mg/L was greater after implementation of the protocol than with usual care, but the difference was nonsignificant (44% [8/18] versus 20% [3/15], p = 0.27). However, the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L was significantly higher after protocol implementation (94% [17/18] versus 53% [8/15], p = 0.012). There was no difference in the median number of vancomycin measurements per treatment day before and after protocol implementation (0.133 versus 0.125, p = 0.99). CONCLUSIONS: At the study institution, the likelihood of achieving recommended vancomycin concentration increased (relative to previous practice) after implementation of a simplified vancomycin dosing protocol for patients undergoing IHD.

CONTEXTE: Les patients recevant une hémodialyse intermittente (HDI) présentent un risque élevé de contracter des infections à Gram positif, souvent traitées à l'aide de vancomycine par intraveineuse (IV). Malgré l'utilisation fréquente de la vancomycine dans les environnements d'HDI, les pratiques portant sur le dosage et le suivi varient entre les cliniciens de l'institution où l'étude s'est déroulée. Il existe également peu de données probantes sur la dose optimale de vancomycine permettant d'atteindre la concentration sérique cible avant l'HDI. OBJECTIFS: L'objectif principal visait à comparer le pourcentage de traitements à la vancomycine, dont la concentration sérique se situait entre 15 et 20 mg/L, lors de la mesure prise avant la troisième séance de HDI, avant et après la mise en place d'un protocole de dosage basé sur le poids. Les objectifs secondaires visaient à comparer le pourcentage de traitements, dont la concentration de vancomycine mesurée avant la troisième séance d'HDI était comprise entre 10 et 22 mg/L, et le nombre de mesures de vancomycine par jour de traitement, avant et après la mise en place du protocole. MÉTHODES: Cette étude quasi expérimentale, menée dans un seul centre, comprenait des patients hospitalisés et ambulatoires ayant subi une HDI et reçu au moins deux doses de vancomycine par IV et dont un échantillon prélevé de manière appropriée avant la troisième séance d'HDI a permis de mesurer la vancomycine. Avant la mise en place du protocole, le dosage de vancomycine était laissé à la discrétion du clinicien (soins habituels). Après sa mise en place, chaque patient recevait une dose de charge de 1000, 1500 ou 2000 mg et une dose de maintenance de 500, 750 ou 1000 mg selon sa masse corporelle. RÉSULTATS: Le pourcentage de traitements dont la concentration de vancomycine mesurée avant la troisième séance d'HDI était comprise entre 15 et 20 mg/L était plus élevé après la mise en place du protocole qu'après les soins habituels, mais la différence n'était pas significative (44 % [8/18] contre 20 % [3/15], p = 0,27). Cependant, le pourcentage de traitements dont la concentration de vancomycine mesurée avant la troisième séance d'HDI était comprise entre 10 et 22 mg/L était significativement plus élevé après la mise en place du protocole (94 % [17/18] contre 53 % [8/15], p = 0,012). Le nombre moyen de mesures de vancomycine par traitement n'avait pas varié entre le jour précédant et le jour suivant la mise en place du protocole (0,133 contre 0,125, p = 0,99). CONCLUSIONS: Dans l'institution où l'étude s'est déroulée, la probabilité d'atteindre la concentration de vancomycine recommandée avait augmenté après la mise en place d'un protocole simplifié de dosage de vancomycine pour les patients recevant une HDI comparativement à une pratique antérieure.