Quiz Ref ID Patients with advanced-stage cancer receive aggressive medical care at the end of life,¹ despite increasing evidence that high-intensity treatments may not be associated with better patient quality of life, outcomes, or caregiver bereavement.² The National Quality Forum and the American Society of Clinical Oncology have jointly endorsed several indicators of overly aggressive end-of-life care (developed by Earle et al³), including repeated hospitalizations, emergency department visits, or admission to an intensive care unit (ICU) within the last month of life, patient receipt of chemotherapy within 2 weeks prior to death, and late or absent hospice referrals.⁴

Purpose: Despite several new treatment options, single- and multi-institution analyses have not clarified whether survival patterns in follicular lymphoma (FL) patients have changed in recent decades. We undertook a study using a large population-based registry to analyze survival patterns among patients with FL. Patients and Methods: Surveillance, Epidemiology, and End Results morphology codes were used to identify 14,564 patients diagnosed with FL between 1978 and 1999. Observed median survival times, Kaplan-Meier survival curves, proportional death hazard ratios, and relative survival rates were calculated. Joinpoint regression analysis was used to identify trends in annual adjusted death hazard ratios. Results: An improvement in survival of all patients with FL was observed between each of three diagnosis eras (1978 to 1985, 1986 to 1992, and 1993 to 1999) by log-rank tests. Among patients with stage-specific data, the median survival time improved from 84 months (95% CI, 81 to 88 months) in the 1983 to 1989 era to 93 months (95% CI, 89 to 97 months) in the 1993 to 1999 era. Similar findings were identified across sex and age groups and for subsets including advanced-stage, large-cell FL and the combined subset of small cleaved- and mixed-cell FL. The inter-era survival advantage observed in white patients was not observed for black patients. The relative risk of death decreased by 1.8% per year over the 1983 to 1999 observation period. Conclusion: The survival of patients with FL in the United States has improved over the last 25 years. The survival improvement may be a result of the sequential application of effective therapies and improved supportive care.

Background. Previous studies indicate that vancomycin is inferior to beta-lactams for treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections. However, it is unclear if this association is true for empiric and definitive therapy. Here, we compared beta-lactams with vancomycin for empiric and definitive therapy of MSSA bloodstream infections among patients admitted to 122 hospitals. Methods. This retrospective cohort study included all patients admitted to Veterans Affairs hospitals from 2003 to 2010 who had positive blood cultures for MSSA. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression. Empiric therapy was defined as starting treatment 2 days before and up to 4 days after the first MSSA blood culture was collected. Definitive therapy was defined as starting treatment between 4 and 14 days after the first positive blood culture was collected. Results. Patients who received empiric therapy with a beta-lactam had similar mortality compared with those who received vancomycin (HR, 1.03; 95% CI, .89–1.20) after adjusting for other factors. However, patients who received definitive therapy with a beta-lactam had 35% lower mortality compared with patients who received vancomycin (HR, 0.65; 95% CI, .52–.80) after controlling for other factors. The hazard of mortality decreased further for patients who received cefazolin or antistaphylococcal penicillins compared with vancomycin (HR, 0.57; 95% CI, .46–.71). Conclusions. For patients with MSSA bloodstream infections, beta-lactams are superior to vancomycin for definitive therapy but not for empiric treatment. Patients should receive beta-lactams for definitive therapy, specifically antistaphylococcal penicillins or cefazolin.

This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4–12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8–8.0) at 9 months. The 24‐hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0–12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4–6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8–20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.