Consensus document from GESITRA-SEIMC on the prevention and treatment of cytomegalovirus infection in transplanted patients

Cytomegalovirus (CMV) infection remains an important complication of transplantation. The last decade has been characterized by improvements to management that has reduced its morbidity and mortality. The advance has been particularly important in the diagnosis and prevention. Several techniques have been developed that allow the increasingly rapid and sensitive diagnosis. The different preventive strategies include use of appropriate blood products, immune globulin, and antiviral agents either as prophylaxis or pre-emptive therapy. The development of effective oral drugs as valganciclovir also represents a new advance. It is necessary to summarize these advances to facilitate the development of local policies reflecting recent changes. The Group of Study of Infections in Transplantation (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has therefore produced actual recommendations in the management of CMV infection after transplantation.     

Rehabilitación respiratoria

Pulmonary rehabilitation (PR) has been shown to improve dyspnea, exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). PR has also shown benefits in diseases other than COPD but the level of evidence is lower. The fundamental components of PR programs are muscle training, education and chest physiotherapy. Occupational therapy, psychosocial support and nutritional intervention should also be considered. Home programs have been shown to be as effective as hospital therapy. The duration of rehabilitation programs should not be less than 8 weeks or 20 sessions. Early initiation of PR, even during exacerbations, has proven safe and effective. The use of oxygen or noninvasive ventilation during training is controversial and dependent on the patient's situation. At present, the best strategy for maintaining the benefits of PR in the long term is unknown. Longer PR programs or telemedicine could play a key role in extending the results obtained.     

Benefits of risk-adapted and mould-specific antifungal prophylaxis in childhood leukaemia

Fluconazole is one of the most commonly used drugs for antifungal prophylaxis in childhood leukaemia. However, its interaction with vincristine may induce neuropathy and the emergence of antifungal drug resistance contributes to substantial mortality caused by invasive fungal infections (IFIs). In a retrospective single-centre study, we compared tolerability and outcome of different antifungal prophylaxis strategies in 198 children with acute leukaemia (median age 5·3 years). Until 2010, antifungal prophylaxis with fluconazole was offered to most of the patients and thereafter was replaced by liposomal amphotericin-B (L-AMB) and restricted to high-risk patients only. Vincristine-induced neurotoxicity was significantly reduced under L-AMB, as the percentage of patients with severe constipation decreased (15·4% vs. 3·7%, before vs. after 31 December·2010, P = 0·01) and stool frequency increased by up to 38% in polyene-treated patients (P = 0·005). Before 2011, 10 patients developed confirmed IFIs, most of them were infected with Aspergillus species. After risk adaption in 2011, IFIs were completely prevented (P = 0·007). L-AMB prophylaxis is beneficial in childhood leukaemia patients, as it offers effective antifungal activity with improved tolerability as compared to fluconazole. The potential impact of our risk-adapted antifungal treatment should be included in current prophylaxis guidelines for childhood leukaemia.     

Usefulness of multidetector computed tomography to differentiate between renal cell carcinoma and oncocytoma. A model validation

Objective:The purpose of this study is to validate a multivariable predictive model previously developed to differentiate between renal cell carcinoma (RCC) and oncocytoma using CT parameters.Methods and materials:We included 100 renal lesions with final diagnosis of RCC or oncocytoma studied before surgery with 4-phase multidetector CT (MDCT). We evaluated the characteristics of the tumors and the enhancement patterns at baseline, arterial, nephrographic and excretory MDCT phases.Results:Histopathologically 15 tumors were oncocytomas and 85 RCCs. RCCs were significantly larger (median 4.4 cm vs 2.8 cm, p = 0.006). There were significant differences in nodule attenuation in the excretory phase compared to baseline (median: 31 vs 42, p = 0.015), with RCCs having lower values. Heterogeneous enhancement patterns were also more frequent in RCCs (85.9% vs 60%, p = 0.027).Multivariable analysis showed that the independent predictors of malignancy were the enhancement pattern, with oncocytomas being more homogeneous in the nephrographic phase [Odds Ratio (OR) 0.16 (95% CI 0.03 to 0.75, p = 0.02)], nodule enhancement in the excretory phase compared to baseline, with RCCs showing lower enhancement [OR 0.96 (95% CI 0.93 to 0.99, p = 0.005)], and a size > 4 cm, with RCCs being larger [OR 5.89 (95% CI 1.10 to 31.58), p = 0.038].Conclusion:The multivariable predictive model previously developed which combines different MDCT parameters, including lesion size > 4 cm, lesion enhancement in the excretory phase compared to baseline and enhancement heterogeneity, can be successfully applied to distinguish RCC from oncocytoma.Advances in knowledge:This study confirms that multiparametric assessment using MDCT (including parameters such as size, homogeneity and enhancement differences between the excretory and the baseline phases) can help distinguish between RCCs and oncocytomas. While it is true that this multiparametric predictive model may not always correctly classify renal tumors such as RCC or oncocytoma, it can be used to determine which patients would benefit from pre-surgical biopsy to confirm that the tumor is in fact an oncocytoma, and thereby avoid unnecessary surgical treatments.     

Type I Tympanoplasty: surgical success and prognostic factors

ObjectivesTo evaluate success rate of type I tympanoplasty in adults and to investigate the importance of selected prognostic factors on graft uptake.Material and methodsRetrospective medical chart review of 155 patients who underwent Type I Tympanoplasty, in our department, from January 2013 to December 2017. Graft uptake rate was evaluated and the effects of prognostic factors on surgical outcome such as sex, smoking and otological surgery history, status of the contralateral ear, size and location of the perforation, middle ear mucosa status, surgical approach and graft material. Preoperative and postoperative audiometric data were collected, and the functional success was determined.ResultsThe overall surgical anatomical success rate was 75%. Analysis of the selected variables, identified as independent prognostic factors of anatomical unsuccess (95% CI): smoking (OR = 3.29, p < .01), middle ear tympanosclerosis (OR = 2.96; p = .04). Perforations above 50% of the tympanic membrane area had a borderline effect on graft uptake (p = .05). There was a significative improvement in the average air conduction thresholds of 7.44 dB and an ABG closure rate at 10 dB and 20 dB was achieved in 47% and 84.5%, respectively. Patients who received temporalis fascia graft had similar hearing gain compared to patients who underwent cartilage tympanoplasty (7.7 vs. 7.3 dB, p = .79).ConclusionType I tympanoplasty is an effective and safe procedure with a high anatomical success rate in the treatment of mucosal COM. Poorer outcomes were found in patients with smoking habits, in those with tympanosclerosis of middle ear mucosa and in larger perforations. These prognostic factors should be considered in surgical planning and patients should be advised to quit smoking. Tympanoplasty with cartilage graft had a hearing outcome comparable to temporalis fascia graft and should be considered in high-risk patients.