The efficacy of peroral endoscopic myotomy vs. pneumatic dilation as treatment for patients with achalasia suffering from persistent or recurrent symptoms after laparoscopic Heller myotomy. A RANDOMIZED CLINICAL TRIAL

For achalasia patients with persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM versus PD for patients with persistent or recurrent symptoms after LHM.

Leggi
Marzo 2023

Lower vs Higher Oxygen Saturation Targets and Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest

To the Editor A recent study compared the effect of 2 oxygen saturation targets on survival after out-of-hospital cardiac arrest. The authors have focused on an important area of postresuscitation care, because hyperoxia (defined as Pao2 >300 mm Hg) has shown to be associated with worse outcomes. In contrast to a 2022 study, the study by Dr Bernard and colleagues did not report any benefit for low oxygen targets, although the oxygen target for the intervention group (peripheral oxygen saturation of 90%-94%) was far below international recommendations. Thus, this trial compared hypoxia with normoxia rather than normoxia with hyperoxia and, not surprisingly, the intervention group experienced more episodes of hypoxemia and rearrest. Although this study was stopped early without having reached the required number of patients due to the COVID-19 pandemic and thus had insufficient statistical power, the study results nearly showed statistical significance (P = .05), with worse survival in the lower oxygen saturation target intervention group (38.3%) vs the standard group (47.9%). Therefore, we are concerned that the wording of the conclusion “…targeting an oxygen saturation of 90%-94%…did not significantly improve survival…” was misleading and did not represent the most important findings of this study. Furthermore, as shown in Table 2 in the article, the first Paco2 measurement in the emergency department was 60 mm Hg in both groups, revealing severe hypoventilation in the out-of-hospital setting that may have influenced the results of the study.

Leggi
Marzo 2023

Lower vs Higher Oxygen Saturation Targets and Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest—Reply

In Reply Regarding our recent study, Drs Wetsch and Böttiger are concerned that a target oxygen saturation of 90% to 94% in the EXACT trial should be considered hypoxia. This target oxygen saturation was justified by a meta-analysis of previous phase 2 trials testing a lower oxygen target in patients with out-of-hospital cardiac arrest. In that meta-analysis, there was a range of different “low” oxygen targets. The largest study was by Young et al, which randomized 166 patients with suspected hypoxic-ischemic encephalopathy to receive an oxygen saturation of 90% to 97% compared with standard care. A total of 37 of 86 patients (43%) assigned to the lower oxygen target and 46 of 78 (59%) assigned to standard oxygen target died by day 180 (odds ratio, 0.53 [95% CI, 0.28-0.98]; P = .04). These data were suggestive that a target oxygen saturation as low as 90% was safe, but required a larger trial to prove benefit. It is acknowledged that current guidelines recommend a target oxygen saturation of 94% to 98% and that an oxygen saturation less than 90% should be avoided. Given the results of the EXACT trial, we agree that there are now compelling data supporting a minimum target oxygen saturation of 94% during prehospital and emergency department care in these patients.

Leggi
Marzo 2023

Cefepime/Enmetazobactam vs Piperacillin/Tazobactam and Complicated Urinary Tract Infection or Acute Pyelonephritis—Reply

In Reply In response to the insightful questions by Dr Hsu and colleagues, the ALLIUM phase 3 study was completed prior to the change in the CLSI piperacillin/tazobactam breakpoints in 2022 and the EUCAST breakpoints in 2021. However, a post hoc outcomes analysis was performed on the primary analysis set, which excluded patients with baseline urinary pathogens with a piperacillin/tazobactam MIC of greater than 16 μg/mL and/or if the pathogen encoded an extended-spectrum β-lactamase. In this analysis, improved outcomes in patients receiving cefepime/enmetazobactam compared with piperacillin/tazobactam were still observed. Although not presented in our article, we performed another post hoc analysis that excluded patients with a baseline pathogen piperacillin/tazobactam MIC of greater than 8 μg/mL, accounting for the new piperacillin/tazobactam breakpoints (susceptible, ≤8 μg/mL). In this analysis, improved outcomes in the cefepime/enmetazobactam group (79.1% [250/316]) compared with the piperacillin/tazobactam group (60.3% [182/302]) were again observed (treatment difference, 18.8% [95% CI, 11.6%-25.7%]; P 

Leggi
Febbraio 2023