Infectious complications in patients randomized to receive allogeneic bone marrow or peripheral blood transplantation

Abstract: Very few data are available on the comparison of infectious complications in peripheral blood stem cell transplantation (PBSCT) and bone marrow transplant (BMT). The objective of this study was to evaluate the severity and frequency of infectious complications in patients randomized to receive PBSCT or BMT. We retrospectively reviewed the charts of all patients included in a randomized clinical trial comparing PBSCT (27 patients) and BMT (29 patients). We analyzed two periods: pre‐engraftment and post‐engraftment. In the pre‐engraftment period, we compared the two groups with respect to the duration of neutropenia, antibiotic use and hospitalization, and documentation of infection. In the post‐engraftment period, we analyzed the occurrence and severity of graft‐versus‐host disease (GVHD), duration of cyclosporine, corticosteroids, antibiotic, antiviral and antifungal prophylaxis, number of episodes of infection, and death rates. Patients receiving PBSCT had shorter duration of neutropenia, but there were no differences in the incidence of infections or duration of antibiotic therapy. Patients receiving PBSCT had a higher incidence of extensive chronic GVHD (65% vs. 39%, P=0.08), longer duration of cyclosporine use (risk ratio [RR] 1.97), corticosteroids (RR 1.66), antibacterial (RR 2.60), antifungal (RR 2.50), anti‐Pneumocystis carinii (RR 2.06) and anti‐cytomegalovirus (RR 1.44) prophylaxis, and more infectious episodes (3.65 vs. 2.32 per 1000 days at risk, RR 1.57). There were no differences in death rates. Multivariate analysis identified the use of steroids as the most significant variable associated with infectious episodes. PBSCT was associated with more infections in the post‐engraftment period.     

Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis

Purpose

To assess the effects of alveolar recruitment maneuvers (ARMs) on clinical outcomes in patients with acute respiratory distress syndrome (ARDS).

Methods

We conducted a search of the MEDLINE, EMBASE, LILACS, CINAHL, CENTRAL, Scopus, and Web of Science (from inception to July 2014) databases for all (i.e. no language restriction) randomized controlled trials (RCTs) evaluating the effects of ARMs versus no ARMs in adults with ARDS. Four teams of two reviewers independently assessed the eligibility of the studies identified during the search and appraised the risk of bias and extracted data from those which were assessed as meeting the inclusion criteria. Data were pooled using the random-effects model. Trial sequential analysis (TSA) was used to establish monitoring boundaries to limit global type I error due to repetitive testing for our primary outcome (in-hospital mortality). The GRADE system was used to rate the quality of evidence.

Results

Our database search identified ten RCTs (1,594 patients, 612 events) which satisfied the inclusion criteria. The meta-analysis assessing the effect of ARMs on in-hospital mortality showed a risk ratio (RR) of 0.84 [95 % confidence interval (CI) 0.74–0.95; I ² = 0 %], although the quality of evidence was considered to be low due to the risk of bias in the included trials and the indirectness of the evidence—that is, ARMs were usually conducted together with other ventilatory interventions which may affect the outcome of interest. There were no differences in the rates of barotrauma (RR 1.11; 95 % CI 0.78–1.57; I ² = 0 %) or need for rescue therapies (RR 0.76, 95 % CI 0.41–1.40; I ² = 56 %). Most trials found no difference between groups in terms of duration of mechanical ventilation and length of stay in the intensive care unit and hospital. The TSA showed that the available evidence for the effect of ARMs on in-hospital mortality is precise in the case of a type I error of 5 %, but it is not precise with a type I error of 1 %.

Conclusions

Although ARMs may decrease the mortality of patients with ARDS without increasing the risk for major adverse events, current evidence is not definitive. Large-scale ongoing trials addressing this question may provide data better applicable to clinical practice.     

Brazilian guidelines for the management of candidiasis – a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia,Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.     

Non-Hispanic Blacks undergoing distal pancreatectomy have higher risk-adjusted rates of morbidity and are more likely to be high-cost outliers

BackgroundFew studies evaluate racial disparities in costs and clinical outcomes for patients undergoing distal pancreatectomy (DP).MethodsWe queried the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing DP. Multivariable regression (MVR) was used to evaluate the association between race and postoperative outcomes.Results2,493 patients underwent DP; 265 (10%) were black, and 221 (8%) were of Hispanic ethnicity. On MVR, black and Hispanic patients were less likely than whites to undergo surgery in high volume centers (OR 0.53, 95% CI [0.40, 0.71]; OR 0.45, 95% CI [0.32, 0.62]). Black patients had a greater risk of postoperative complication (OR 1.40, 95% CI [1.07, 1.83]), 90-day readmission (OR 1.53, 95% CI [1.15, 2.02]), prolonged length of stay (OR 1.74, 95% CI [1.25–2.44]), and of being a high cost outliers (OR 1.40, 95% CI [1.02, 1.91]) compared to white patients.ConclusionBlack patients have increased risk of having a postoperative complication, prolonged hospitalization, and of being a high-cost outlier than non-Hispanic whites.     

Transesophageal echocardiography in an emergency setting. A district general hospital experience.

Transesophageal echocardiography is an extremely useful technique for the study of various cardiovascular pathologies. In the particular setting of emergency, it is of great value for prompt diagnosis and appropriate therapy. It was our aim to evaluate, in our hospital, the benefits obtained by the use of transesophageal echocardiography in an emergency setting. We retrospectively studied patients who underwent transesophageal echocardiography (TEE) in an emergency setting, from June 1997 to December 2002, evaluating demographic characteristics, indication to perform TEE, benefit obtained (diagnosis or exclusion of initial diagnosis), and technique-related complications. There were 97 transesophageal echocardiograms performed in an emergency setting in the period under consideration, accounting for 19.3% of the total number of exams. Fifty-two patients (53.6%) were male, mean age 63.9 +/- 12.7. Nineteen patients (19.6%) were on assisted ventilation. The indications to perform TEE were: possible massive or submassive pulmonary thromboembolism in 32 patients (33.0%); suspected aortic dissection in 19 (19.6%); shock with inconclusive transthoracic echocardiogram in ten (10.3%); possible endocarditis in eight (8.2%); possible prosthetic valve dysfunction in seven (7.2%); intracardiac mass in six (6.2%); search for cardiac source of embolism in five (5.2%); possible mechanical complication of acute myocardial infarction in four (4.1%); pre-electrical cardioversion study in four patients with atrial fibrillation (4.1%); and suspected congenital heart disease in two (2.1%). TEE examination yielded additional information and helped in the therapeutic decision in 88 patients (90.7%), leading to a diagnosis in 49 (50.6%), which was different from the initial diagnostic hypothesis in four, and exclusion of the suspected diagnosis in 39 (40.1%). There was only one minor complication (1.0%) and no TEE-related mortality. We concluded that transesophageal echocardiography is an extremely useful and safe cardiovascular diagnostic technique in an emergency setting in a district general hospital, enabling a diagnosis to be reached or excluded in almost all patients, which is essential for implementing appropriate therapy.     

Mycosis fungoides bullosa

A case of a 52-year-old man with mycosis fungoides bullosa. plaque-stage IIA, follicular mucinosis and milia is described. The disease started about 15 years ago and evolved with periods of remission induced by photochemotherapy (PUVA) and, later, by topical nitrogen mustard and etretinate. Vesiculobullous lesions, alopecia and milia sequentially appeared in the course of its evolution. Besides characteristic features of mycosis fungoides, histopathology revealed subepidermal vesicles and follicular mucinosis associated with lymphoid cells (CD3⁺). The pathophysiology of these particular aspects of the mycosis fungoides is discussed.