Sequencing of chemotherapy and radiation therapy for early breast cancer.

BACKGROUND: After surgery for localised breast cancer, adjuvant radiotherapy improves both local control and breast cancer specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early stage breast cancer is not clear. OBJECTIVES: To determine the effects of different sequencing of chemotherapy and radiotherapy for women with early breast cancer. SEARCH STRATEGY: We searched the Cochrane Breast Cancer Group Specialized Register (10 March 2005). Details of the search strategy and methods of coding are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'. SELECTION CRITERIA: Randomised controlled trials evaluating different sequencing of chemotherapy and radiotherapy were included. DATA COLLECTION AND ANALYSIS: We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included studies. We derived odds ratios (OR) and risk ratios from the available numerical data. Hazard ratios were extracted directly from text. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments. MAIN RESULTS: Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for survival, distant metastases or local recurrence, based on 853 randomised patients in two trials. One of these two trials (647 women) provided data on toxicity. Haematological toxicity (OR 1.43, confidence interval (CI) 1.01 to 2.03) and oesophageal toxicity (OR 1.44, CI 1.03 to 2.02) were significantly increased with concurrent therapy, and nausea and vomiting were significantly decreased (OR 0.70, CI 0.50 to 0.98). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), radiotherapy before chemotherapy was associated with a significantly increased risk of neutropenic sepsis (OR 2.96, 95% CI 1.26 to 6.98) compared with chemotherapy before radiotherapy, but other measures of toxicity were not significantly different. AUTHORS' CONCLUSIONS: The data included in this review, from three well conducted randomised trials, suggest that different methods of sequencing chemotherapy and radiotherapy do not appear to have a major effect on survival or recurrence for women with breast cancer if radiation therapy is commenced within 7 months after surgery.

Introduction of a plasmid encoding the OHIO-1 beta-lactamase to an intermediate care ward by patient transfer.

A prospective study of 147 intermediate care ward (ICW) patients for acquisition of gentamicin-resistant Enterobacteriaceae (GRE) was carried out. Fifty (34%) were colonized or infected with one or more strains of GRE. Fifteen of these patients and one nurse were colonized with 22 strains (including ten species) of GRE bearing identical 60 kb plasmids encoding a novel beta-lactamase determinant, OHIO-1 and ANT(2"). Analysis of the time course of colonized patients on the ICW revealed one probable episode of cross-transmission. Five colonized patients had been residing in the ICW from one to four months prior to study initiation. Eight patients were admitted to the ICW from other hospital areas already colonized and one additional patient acquired colonization on the ICW from an unknown source. Thus, eight of ten patients admitted to the ICW during the prospective study were already colonized on admission to the ICW. To control this level of colonization it would therefore be necessary to direct efforts at limiting admission of colonized patients or attempting to eliminate the strain from persistently colonized patients, rather than trying to limit transmission within the ward.

The epidemiology of gentamicin-resistant Pseudomonas aeruginosa on an intermediate care unit.

The authors conducted a prospective six-month study of colonization by gentamicin-resistant Pseudomonas aeruginosa on an intermediate care unit at a Cleveland, Ohio hospital with the use of selective culture techniques, serotyping, and plasmid analysis. Thirty-five of 163 patients (21%) were culture positive at least once for gentamicin-resistant Pseudomonas aeruginosa. Patient samples, environmental cultures, and personnel hand cultures revealed no common source for the organisms. Plasmid profiling added little to the serotyping data. Only nonambulation and length of stay on the unit were significant independent risk factors for colonization with gentamicin-resistant Pseudomonas aeruginosa by multiple logistic regression analysis. Age, use of urinary catheters, exposure to antibiotics, and duration of antibiotic use were correlated with one or both of the independent risk factors, but were not themselves independently associated with colonization by these resistant organisms. Cross-colonization apparently was not an important mode of dissemination of gentamicin-resistant Pseudomonas aeruginosa on this intermediate care unit. The identified risk factors appear to be more important than cross-colonization, and control strategies should address these issues.

Prevalence of colonization with antibiotic resistant gram-negative bacilli in a nursing home care unit: the importance of cross-colonization as documented by plasmid analysis.

A prevalence study was carried out on a 100-bed Veterans Administration nursing home care unit to determine the extent of colonization with gentamicin-resistant gram-negative bacilli (GRGNB). Hand cultures of 12 employees and 17 environmental cultures were negative. Twenty-six of 86 (30%) patients were colonized with 49 GRGNB. Sixteen patients (19%) had urinary colonization. Multivariate analysis revealed significant associations between rectal or perineal colonization (P less than 0.01), and the presence of a urinary device (82% condom catheters) (P less than 0.05), with urinary colonization. The most common isolates were Providencia stuartii (20), Escherichia coli (nine) and Klebsiella pneumoniae (nine). Twenty-six of 49 isolates carried plasmids. Restriction endonuclease digestion of plasmid DNA was performed for 21. Cross-colonization, as defined by the presence of the identical species with the identical restriction endonuclease digestion profile of purified plasmid DNA found in different patients, was observed for eight of 21 (38%) strains. All were geographically clustered. No strains could transfer gentamicin-resistance by conjugation and only two plasmids could transform our E coli recipient to gentamicin resistance. One E coli plasmid was identical to two Citrobacter freundii plasmids and a P stuartii plasmid isolated from three different patients. This 105 kb plasmid is conjugative and encodes resistance to ampicillin, carbenicillin, tetracycline, and sulfonamides. Thus, 57% of strains were cross-colonizing or contained identical R-plasmids. Southern hybridization using a 1 kb TEM-1 gene probe demonstrated sequences homologous to this probe in five of five nursing home plasmids examined.(ABSTRACT TRUNCATED AT 250 WORDS)