Hematopoietic cell transplant nurse coordinators' perceptions of related donor care: a European survey from the EBMT Nurses Group

Allogeneic haematopoietic cell transplantation (HCT) is a curative procedure for patients with haematological malignancies and immune deficiencies. A human leukocyte antigen (HLA) identical sibling is only available for 25-35% of patients in need. The improvement in haplo-identical transplantation has led to a marked increase in cell donation from relatives. Despite international recommendations, discrepancies in related-donors (RD) care exist between centres, particularly regarding medical suitability criteria, consenting procedures and donor follow-up. This European survey aimed to explore hematopoietic cell transplantation coordinators nurses' (HCT-CNs) perceptions of RD care, in particular the association with the presence or not of an independent unit (IU). Ninety-three HCT-CNs from seventy-six EBMT centres responded, representing 19 countries (response rate: 27%). Our results did not show a significant association between IU and HCT-CNs perceptions of related-donors care. The practices for RD care vary among centres regarding presence or not of an IU (48%), person caring for RD (haematologist in 54%, HCT physician in 17%, HCT-CNs in 20%), person to whom the results of HLA typing are communicated, use of a booklet for RD, follow-up or not and periodicity of follow-up. Qualitative data highlight the related-donation ethical issues and the need for improvement in RD care. HCT-CNs' main concerns were: the necessary confidentiality to insure the voluntary status of RD, the perceived conflict of interest felt by professionals when managing both patients and RD, plus the psychosocial aspects of related-donation. Even if there is a variety of a practice among centres, the presence of an IU is not significantly associated with an improvement in RD care.

Origin, distribution, and geochemistry of arsenic in the Altiplano-Puna plateau of Argentina, Bolivia, Chile, and Perú

Elevated concentrations of arsenic in water supplies represent a worldwide health concern. In at least 14 countries of South America, high levels have been detected relative to international standards and guidelines. Within these countries, the high plateau referred to as the "Altiplano-Puna", encompassing areas of Argentina, Bolivia, Chile, and Perú, exhibits high arsenic concentrations that could be affecting 3 million inhabitants. The origins of arsenic in the Altiplano-Puna plateau are diverse and are mainly natural in origin. Of the natural sources, the most important correspond to mineral deposits, brines, hot springs, and volcanic rocks, whereas anthropogenic sources are related to mining activities and the release of acid mine drainage (AMD). Arsenic is found in all water types of the Altiplano-Puna plateau over a wide range of concentrations (0.01 mg·L^-1 < As in water > 10 mg·L^-1) which in decreasing order correspond to: AMD, brines, saline waters, hot springs, rivers affected by AMD, rivers and lakes, and groundwater. Despite the few studies which report As speciation, this metalloid appears mostly in its oxidized form (As[V]) and its mobility is highly susceptible to the influence of dry and wet seasons. Once arsenic is released from its natural sources, it also precipitates in secondary minerals where it is generally stable in the form of saline precipitates and Fe oxides. In relation to human health, arsenic adaptation has been detected in some aboriginal communities of the Puna together with an efficient metabolism of this metalloid. Also, the inefficient methylation of inorganic As in women of the Altiplano might lead to adverse health effects such as cancer. Despite the health risks of living in this arsenic-rich environment with limited water resources, not all of the Altiplano-Puna is properly characterized and there exists a lack of information regarding the basic geochemistry of arsenic in the region.

Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013)

OBJECTIVES

Timely HIV diagnosis and presentation to medical care are important for treatment and prevention. Our objective was to measure late diagnosis, delayed presentation and late presentation among individuals in the Ontario HIV Treatment Network Cohort Study (OCS) who were newly diagnosed in Ontario.

METHODS

The OCS is a multi-site clinical cohort study of people living with HIV in Ontario, Canada. We measured prevalence of late diagnosis [CD4 count < 350 cells/μL or an AIDS-defining condition (ADC) within 3 months of HIV diagnosis], delayed presentation (≥ 3 months from HIV diagnosis to presentation to care), and late presentation (CD4 count < 350 cells/μL or ADC within 3 months of presentation). We identified characteristics associated with these outcomes and explored their overlap.

RESULTS

A total of 1819 OCS participants were newly diagnosed in Ontario from 1999 to 2013. Late diagnosis (53.0%) and presentation (54.0%) were common, and a quarter (23.1%) of participants were delayed presenters. In multivariable models, the participants of delayed presentation decreased over calendar time, but that of late diagnosis/presentation did not. Late diagnosis contributed to the majority (> 87%) of late presentation, and the prevalence of delayed presentation was similar among those diagnosed late versus early (13.4 versus 13.4%, respectively; P = 0.99). Characteristics associated with higher odds of late diagnosis/presentation in multivariable analyses included older age at diagnosis/presentation; African, Caribbean and Black race/ethnicity; Indigenous race/ethnicity; female sex; and being a male who did not report sex with men. There were lower odds of late diagnosis/presentation among participants who had ever injected drugs. In contrast, delayed presentation risk factors included younger age at diagnosis and having ever injected drugs.

CONCLUSIONS

Late presentation is common in Ontario, as it is in other high-income countries. Our findings suggest that efforts to reduce late presentation should focus on facilitating earlier diagnosis for the populations identified in this analysis.

Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience

INTRODUCTION

The role of extracorporeal support for patients with septic shock remains unclear.

METHODS

We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database.

RESULTS

Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO₂/FiO₂ ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month).

CONCLUSION

VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.

HCV genotype 4, 5 and 6: Distribution of viral subtypes and sustained virologic response rates in clinical trials of approved direct-acting antiviral regimens

Multiple direct-acting antiviral (DAA)-based regimens are now available for all hepatitis C virus (HCV) genotypes (GTs). Because HCV GT 4, 5 and 6 are less common in the United States (US) and worldwide, relatively small numbers of participants with these GTs were evaluated in individual clinical trials. To provide a comprehensive description of subtype diversity and treatment outcomes in clinical trials for these less common GTs, we analysed data from 744 participants with HCV GT4 (n = 573), GT5 (n = 81), or GT6 (n = 90) across 18 clinical trials of DAA regimens. These data are from US New Drug Applications submitted between 2014 and 2017, and our analyses included only approved regimens. Excluding unresolved or mixed subtypes, the distribution of reported GT4 subtypes was 49% 4a, 31% 4d and 16% for one of 14 other subtypes. The distribution of GT6 subtypes was 39% 6a, 27% 6e, 8% 6 L and 23% for one of 11 other subtypes. Across approved regimens, sustained virologic response rates 12 weeks post-treatment (SVR12) for GT 4, 5 and 6 ranged from 91% to 100%, 93% to 97% and 96% to 100%, respectively. SVR12 by GT4 subtype ranged from 96% to 100% for 4a and 81% to 100% for 4d. Virologic failures occurred in GT 4a, 4b, 4d and 4r. For GT6, SVR12 was 100% for all subtypes except 6 L, for which 1 of 7 participants experienced virologic failure. To our knowledge, this is the largest compilation of HCV GT 4, 5 or 6 clinical trial data. These analyses may be useful for clinicians treating HCV GT 4, 5 or 6.

Pneumothorax management: are the guidelines all-encompassing for the purpose of Acute Medicine?

Pneumothorax is defined as the presence of air in the pleural space, between the lung and the chest wall. It is a significant global health problem, with considerable morbidity and healthcare costs. Best management strategy remains controversial, with significant variation in practise, both nationally and internationally. The lack of consensus is driven by the paucity of the evidence base. Current research trials, particularly those looking at ambulatory management, are making progress and may help streamline future guidelines. This review presents five case reports of patients treated with methods which are not entirely synchronous with the current British Thoracic Society (BTS) guidelines; providing guidance for acute medical physicians who are routinely presented with such cases and exploring future developments in pneumothorax management.