De-escalation therapy among bacteraemic patients with community-acquired pneumonia

There is no evidence supporting the use of de-escalation therapy (DET) among patients with community-acquired pneumonia (CAP). We assessed the outcomes associated with DET among bacteraemic CAP patients. We performed a secondary analysis of the Community-Acquired Pneumonia Organization database, which contains data on 660 bacteraemic patients hospitalized because of CAP in 35 countries (2001-2013). Exclusion criteria were death within 72 h from admission and an inappropriate empirical antibiotic regimen. DET was defined as changing an appropriate empirical broad-spectrum regimen to a narrower-spectrum regimen according to culture results within 7 days from hospital admission. Two study groups were identified: patients whose antibiotic therapy was de-escalated (the DET group), and patients whose antibiotic therapy was not de-escalated (the N-DET group). The primary study outcome was 30-day mortality. Two hundred and sixty-one bacteraemic CAP patients were included. Gram-positive bacteria were responsible for 88.1% of the cases (Streptococcus pneumoniae, 75.9%). Gram-negative bacteria were responsible for for 7.3% of the cases. DET was performed in 165 patients (63.2%). The N-DET group was characterized by a more severe presentation at admission. After adjustment for confounders, DET was not associated with an increased risk of 30-day mortality. DET seems to be safe among bacteraemic patients with CAP. Randomized clinical trials are warranted to further explore these findings.

Efficacy and safety of fosfomycin plus imipenem as rescue therapy for complicated bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus: a multicenter clinical trial

BACKGROUND

There is an urgent need for alternative rescue therapies in invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the clinical efficacy and safety of the combination of fosfomycin and imipenem as rescue therapy for MRSA infective endocarditis and complicated bacteremia.

METHODS

The trial was conducted between 2001 and 2010 in 3 Spanish hospitals. Adult patients with complicated MRSA bacteremia or endocarditis requiring rescue therapy were eligible for the study. Treatment with fosfomycin (2 g/6 hours IV) plus imipenem (1 g/6 hours IV) was started and monitored. The primary efficacy endpoints were percentage of sterile blood cultures at 72 hours and clinical success rate assessed at the test-of-cure visit (45 days after the end of therapy).

RESULTS

The combination was administered in 12 patients with endocarditis, 2 with vascular graft infection, and 2 with complicated bacteremia. Therapy had previously failed with vancomycin in 9 patients, daptomycin in 2, and sequential antibiotics in 5. Blood cultures were negative 72 hours after the first dose of the combination in all cases. The success rate was 69%, and only 1 of 5 deaths was related to the MRSA infection. Although the combination was safe in most patients (94%), a patient with liver cirrhosis died of multiorgan failure secondary to sodium overload. There were no episodes of breakthrough bacteremia or relapse.

CONCLUSIONS

Fosfomycin plus imipenem was an effective and safe combination when used as rescue therapy for complicated MRSA bloodstream infections and deserves further clinical evaluation as initial therapy in these infections.

Iron, cadmium, and chromium in seagrass (Thalassia testudinum) from a coastal nature reserve in karstic Yucatán

The management of protected areas in karstic regions is a challenge because flooded cave systems form there and provide underground hydrological conducts that may link different zones. As a consequence, affectations to the protected areas can possibly occur as a consequence of human activities in remote areas and may therefore pass undetected. Thus, the monitoring of possible contaminants in these regions is becoming imperative. In this work, we analyze the concentration of essential (iron) and non-essential metals (cadmium and chromium) in the seagrass Thalassia testudinum that grows in Yalahau Lagoon, located in a near-to-pristine protected area of the Yucatán Peninsula, close to the rapidly developing touristic belt of the Mexican Caribbean. Salinity and silicate patterns show that Yalahau is an evaporation lagoon, where groundwater discharge is important. High iron (> 400 μg/g), cadmium (>4 μg/g), and chromium (≈ 1 μg/g) concentrations were found in the area of highest groundwater input of the lagoon. High levels (5.1 μg/g) were also found near the town dump. In the rest of the sampling sites, metal concentrations remained near to background levels as estimated from other works. Temporal changes of concentrations in the seagrass tissues show also a local input and an input from the groundwater that could provoke an environmental problem in the Yalahau Lagoon in the near future.

Sensitive thermal transitions of nanoscale polymer samples using the bimetallic effect: application to ultra-thin polythiophene

A sensitive nanocalorimetric technology based on microcantilever sensors is presented. The technology, which combines very short response times with very small sample consumption, uses the bimetallic effect to detect thermal transitions. Specifically, abrupt variations in the Young's modulus and the thermal expansion coefficient produced by temperature changes have been employed to detect thermodynamic transitions. The technology has been used to determine the glass transition of poly(3-thiophene methyl acetate), a soluble semiconducting polymer with different nanotechnological applications. The glass transition temperature determined using microcantilevers coated with ultra-thin films of mass = 10(-13) g is 5.2 °C higher than that obtained using a conventional differential scanning calorimeter for bulk powder samples of mass = 5 × 10(-3) g. Atomistic molecular dynamics simulations on models that represent the bulk powder and the ultra-thin films have been carried out to provide understanding and rationalization of this feature. Simulations indicate that the film-air interface plays a crucial role in films with very small thickness, affecting both the organization of the molecular chains and the response of the molecules against the temperature.

Cytokines and neutrophils responses in influenza pneumonia

This case report shows a striking correlation of remarkable brief high levels of pro- and anti-inflammatory cytokines coupled with increased neutrophil activation, followed by a sharp decrease in cytokine levels and increased neutrophil apoptosis associated with the favorable clinical outcomes of a patient with severe influenza infection. The host response examined in our case is not complete, given it did not assess the full spectrum of host response. The brief neutrophil and cytokine response seen in our case in the absence of antiviral therapy and in the presence of methotrexate immunosuppressive therapy rise the question as to whether the latter optimally modulated the macrophage function, resulting in a favorable outcome of severe influenza viral infection.

Incidence of respiratory viruses in patients with community-acquired pneumonia admitted to the intensive care unit: results from the Severe Influenza Pneumonia Surveillance (SIPS) project

Few patients with community-acquired pneumonia (CAP) require admission to the intensive care unit (ICU-CAP). However, they represent the most severe form of the disease. An understanding of the etiologic agents of ICU-CAP may lead to better treatment decisions and patient outcomes. The objective of this study was to determine the incidence of respiratory viruses in patients with ICU-CAP. This was an observational study conducted in six Kentucky hospitals from December 2008 through October 2011. A case of ICU-CAP was defined as a patient admitted to an ICU with the diagnosis of CAP. The Luminex xTAG multiplex polymerase chain reaction (PCR) assay was used for viral identification. A total of 468 adult and pediatric patients with ICU-CAP were enrolled in the study. A total of 92 adult patients (23 %) and 14 pediatric patients (19 %) had a respiratory virus identified. Influenza was the most common virus identified in adults and the second most common in pediatric patients. This study suggests that respiratory viruses may be common etiologic agents of pneumonia in patients with ICU-CAP. The Centers for Disease Control and Prevention (CDC) recommend empiric anti-influenza therapy during the winter for hospitalized patients with CAP. This study supports this recommendation in patients with ICU-CAP.

Abstract P2-11-05: Work status and financial stability during treatment for early breast cancer: a pilot study of an ethnically diverse sample

Background: Black and Latina women have lower rates of return to work than non-Latina whites (NLW) after breast cancer treatment. We recently showed that stopping work during chemotherapy is associated with not returning to work for 5 years after treatment. Little is known about the impact of breast cancer on employment outcomes in other low-English proficiency (LEP) immigrant or minority groups. The ongoing longitudinal Breast Cancer and the Workforce study measures work status in LEP immigrants and ethnic minorities undergoing breast cancer treatment with curative intent. For this pilot, we assessed work status and financial stability during treatment.

Methods: Women aged 18–64, undergoing treatment for stage I-III breast cancer, employed at diagnosis, and able to consent in English, Korean, Mandarin, or Spanish were recruited at 3 community oncology clinics and an NCI-designated cancer center. Participants enrolled any time prior to completing their last treatment (chemo, XRT, or surgery) and self-administered web surveys with in-person assistance, as needed, in their preferred language. Demographic, financial, and pre- and post-diagnosis employment characteristics were analyzed using descriptive statistics.

Results: The sample (n = 61) median age was 48 years. 20 (33%) were black, 14 (23%) NLW, 11 (18%) Latina, 8 (13%) Korean, 7 (12%) Chinese, and 1 (2%) other. 37 (61%) were foreign born, 35 (58%) had <college education, 30 (49%) had annual household income <$50,000. 41 (69%) had private insurance, 14 (24%) Medicaid or Emergency Medicaid, and 2 (3%) Medicare/VA. Before diagnosis, 47 (78%) worked full time and 13 (22%) part time. 36 (60%) had white collar jobs (37% manager/professional, 2% arts/media, 22% sales/admin. support); 24 (40%) had blue collar jobs (5% fabricators/laborers; 35% service). 32 (52%) had paid sick leave available at work; 33 (57%) had disability pay. Most were undergoing active therapy: 44 (75%) receiving chemotherapy (7% neo-adjuvant), 3 (5%) post-surgery awaiting adjuvant therapy, 7 (11%) receiving XRT and 5 (8%) awaiting surgery.

When surveyed, 25 (41%) were working full time, 11 (18%) part time and 25 (41%) not working (13% on disability, 16% on paid sick leave, 12% other). 31 (51%) changed work status – stopped working or reduced hours. Of pre-diagnosis full-time workers (n = 47), 23 (49%) changed work status – 4 (9%) to part-time, 8 (17%) sick leave, 7 (15%) disability and 4 (9%) stopped working. Of pre-diagnosis part-time workers (n = 13), 6 (46%) changed status – 2 (16%) sick leave, 1 (8%) disability and 3 (23%) stopped working. Overall, 26 (43%) had less money to spend on food since starting treatment; 31 (53%) did not have enough money to cover their needs.

Discussion: In this pilot, 51% of women changed work status during breast cancer treatment. 41% stopped working, of whom almost a third did not have sick leave or disability. 43% experienced food insecurity during treatment, and 53% said they did not have enough money to cover their needs. Additional research is needed to understand the factors that disrupt work during or soon after treatment, how these factors vary for low-income and minority groups, and to better define the impact of change in work status on financial stability.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-05.

Automatic assistance to Parkinson's disease diagnosis in DaTSCAN SPECT imaging

PURPOSE

In this work, an approach to computer aided diagnosis (CAD) system is proposed as a decision-making aid in Parkinsonian syndrome (PS) detection. This tool, intended for physicians, entails fully automatic preprocessing, normalization, and classification procedures for brain single-photon emission computed tomography images.

METHODS

Ioflupane[(123)I]FP-CIT images are used to provide in vivo information of the dopamine transporter density. These images are preprocessed using an automated template-based registration followed by two proposed approaches for intensity normalization. A support vector machine (SVM) is used and compared to other statistical classifiers in order to achieve an effective diagnosis using whole brain images in combination with voxel selection masks.

RESULTS

The CAD system is evaluated using a database consisting of 208 DaTSCAN images (100 controls, 108 PS). SVM-based classification is the most efficient choice when masked brain images are used. The generalization performance is estimated to be 89.02 (90.41-87.62)% sensitivity and 93.21 (92.24-94.18)% specificity. The area under the curve can take values of 0.9681 (0.9641-0.9722) when the image intensity is normalized to a maximum value, as derived from the receiver operating characteristics curves.

CONCLUSIONS

The present analysis allows to evaluate the impact of the design elements for the development of a CAD-system when all the information encoded in the scans is considered. In this way, the proposed CAD-system shows interesting properties for clinical use, such as being fast, automatic, and robust.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.